Provider Demographics
NPI:1578117388
Name:VALDOSTA STATE UNIVERSITY
Entity Type:Organization
Organization Name:VALDOSTA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, ATHLETIC TRAINING CLINIC
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:LAT, ATC
Authorized Official - Phone:229-253-2890
Mailing Address - Street 1:1500 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31698-0100
Mailing Address - Country:US
Mailing Address - Phone:229-245-2890
Mailing Address - Fax:229-259-5129
Practice Address - Street 1:2525 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1735
Practice Address - Country:US
Practice Address - Phone:229-253-2890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VALDOSTA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty