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Organization
CENTRAL STATE UNIVERSITY
Active
Organization
CENTRAL STATE UNIVERSITY
Active
Other names
Central State Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
MOUZON BASS III (AGENT)
(972) 367-4845
Entity
Organization
Contact information
Practice address
1400 BRUSH ROW RD, WILBERFORCE, OH 45384-5800
(937) 925-3748
(972) 367-3451
Mailing address
PO BOX 650850, DALLAS, TX 75265-0850
(972) 367-4845
(972) 367-3451
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
NULL
207Q00000X
Family Medicine Physician
Primary
—
—
207QS0010X
Sports Medicine (Family Medicine) Physician
—
NULL
207QS0010X
Sports Medicine (Family Medicine) Physician
—
—
Other
Enumeration date
05/08/2015
Last updated
05/08/2015
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