Provider Demographics
NPI:1053864504
Name:SOUTH DAKOTA STATE UNIVERSITY
Entity Type:Organization
Organization Name:SOUTH DAKOTA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ATHLETIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-688-5299
Mailing Address - Street 1:2820 HPER CTR
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57007-1497
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2820 HPER CTR
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57007-1497
Practice Address - Country:US
Practice Address - Phone:605-688-4003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD05212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty