Provider Demographics
NPI:1205186061
Name:CALIFORNIA STATE UNIVERSITY FRESNO ATHLETIC CORPORATION
Entity Type:Organization
Organization Name:CALIFORNIA STATE UNIVERSITY FRESNO ATHLETIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ATHLETICS
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-278-4905
Mailing Address - Street 1:1620 E BULLDOG LN
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93740-0001
Mailing Address - Country:US
Mailing Address - Phone:559-278-4170
Mailing Address - Fax:559-278-8355
Practice Address - Street 1:1620 E BULLDOG LN
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93740-0001
Practice Address - Country:US
Practice Address - Phone:559-278-4170
Practice Address - Fax:559-278-8355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty