Organization
EASTERN NEW MEXICO UNIVERSITY
Active
Other names
ENMU Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
MOUZON BASS III (AGENT)
(972) 367-4845
Entity
Organization
Contact information
Practice address
1500 S AVENUE K, PORTALES, NM 88130-7400
(972) 367-4845
(972) 367-3451
Mailing address
PO BOX 650850, DALLAS, TX 75265-0850
(800) 555-9073
(972) 367-3452
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
207QS0010X
Sports Medicine (Family Medicine) Physician
—
—
Other
Enumeration date
06/30/2015
Last updated
06/30/2015
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