Provider Demographics
NPI:1043648173
Name:GRAMBLING STATE UNIVERSITY
Entity Type:Organization
Organization Name:GRAMBLING STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF STUDENT HEALTH SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:OUTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:318-274-2351
Mailing Address - Street 1:403 MAIN ST
Mailing Address - Street 2:P.O. BOX 4251
Mailing Address - City:GRAMBLING
Mailing Address - State:LA
Mailing Address - Zip Code:71245-2715
Mailing Address - Country:US
Mailing Address - Phone:318-274-2351
Mailing Address - Fax:
Practice Address - Street 1:403 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAMBLING
Practice Address - State:LA
Practice Address - Zip Code:71245-2715
Practice Address - Country:US
Practice Address - Phone:318-274-2351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health