Organization
FORT VALLEY STATE UNIVERSITY
Active
Organization
FORT VALLEY STATE UNIVERSITY
Active
Other names
FVSUSports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
MOUZON BASS III (AGENT)
(972) 367-4845
Entity
Organization
Contact information
Practice address
1005 STATE UNIVERSITY DR, FORT VALLEY, GA 31030-4313
(478) 825-6195
Mailing address
PO BOX 650850, DALLAS, TX 75265-0850
(800) 555-9073
(972) 367-3452
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
207RS0010X
Sports Medicine (Internal Medicine) Physician
—
—
Other
Enumeration date
08/10/2015
Last updated
08/10/2015
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