Basic Information
| Provider Information | |||||||||
| NPI: | 1730555400 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SNOW COLLEGE | ||||||||
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| OtherOrganizationName: | SNOW COLLEGE SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650850 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723674845 | ||||||||
| FaxNumber: | 9723673451 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 E. COLLEGE WAY | ||||||||
| Address2: | |||||||||
| City: | EPHRAIM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005559073 | ||||||||
| FaxNumber: | 9723673452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2015 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | BASS | ||||||||
| AuthorizedOfficialFirstName: | MOUZON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
| AuthorizedOfficialTelephone: | 9723674845 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | HANDY | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.