Provider Demographics
NPI:1083015960
Name:SOUTHERN VIRGINIA UNIVERSITY
Entity Type:Organization
Organization Name:SOUTHERN VIRGINIA UNIVERSITY
Other - Org Name:SVU SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MOUZON
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:972-367-4845
Mailing Address - Street 1:15305 DALLAS PKWY STE 800
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6415
Mailing Address - Country:US
Mailing Address - Phone:972-367-4845
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY HILL DR
Practice Address - Street 2:KNIGHT SPORTS ARENA
Practice Address - City:BUENA VISTA
Practice Address - State:VA
Practice Address - Zip Code:24416-3038
Practice Address - Country:US
Practice Address - Phone:540-261-4931
Practice Address - Fax:540-266-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health