Provider Demographics
NPI:1164704995
Name:CLEVELAND STATE UNIVERSITY
Entity Type:Organization
Organization Name:CLEVELAND STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD ATHLETICS TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LACSAMANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-687-5287
Mailing Address - Street 1:PO BOX 819020
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75381-9020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2214
Practice Address - Country:US
Practice Address - Phone:216-687-5287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health