Provider Demographics
NPI:1265678817
Name:WAKE FOREST UNIVERSITY
Entity Type:Organization
Organization Name:WAKE FOREST UNIVERSITY
Other - Org Name:WAKE FOREST UNIVERSITY SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT ATHLETIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:336-758-5620
Mailing Address - Street 1:WINGATE ROAD, REYNOLDS GYMNASIUM
Mailing Address - Street 2:ROOM 106
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106
Mailing Address - Country:US
Mailing Address - Phone:336-758-5620
Mailing Address - Fax:336-758-6149
Practice Address - Street 1:WINGATE ROAD, REYNOLDS GYMNASIUM
Practice Address - Street 2:ROOM 106
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106
Practice Address - Country:US
Practice Address - Phone:336-758-5620
Practice Address - Fax:336-758-6149
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE FOREST UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-05
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy