Provider Demographics
NPI:1154486884
Name:CLAYTON STATE UNIVERSITY
Entity Type:Organization
Organization Name:CLAYTON STATE UNIVERSITY
Other - Org Name:CLAYTON STATE ATHLETICS
Other - Org Type:Other Name
Authorized Official - Title/Position:ATHLETIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ERLACHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-466-4672
Mailing Address - Street 1:2000 CLAYTON STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1250
Mailing Address - Country:US
Mailing Address - Phone:678-466-5257
Mailing Address - Fax:678-466-4699
Practice Address - Street 1:2000 CLAYTON STATE BOULEVARD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-0285
Practice Address - Country:US
Practice Address - Phone:678-466-5257
Practice Address - Fax:678-466-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
GAAT-0018162255A2300X
GAAT-0001492255A2300X
GAAT0007602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52206789OtherBCBS PROVIDER NUMBER