Organization
EAST TENNESSEE STATE UNIVERSITY
Active
Other names
ETSU Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
MOUZON BASS III (ADMINISTRATOR/AGENT)
(972) 367-4845
Entity
Organization
Contact information
Practice address
1081 JOHN ROBERT BELL DR, RM W-127, JOHNSON CITY, TN 37614
(972) 367-4845
Mailing address
15305 DALLAS PKWY STE 800, ADDISON, TX 75001-6415
(972) 367-4845
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Enumeration date
01/24/2020
Last updated
12/17/2021
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