Provider Demographics
NPI:1730467648
Name:DELTA STATE UNIVERSITY
Entity Type:Organization
Organization Name:DELTA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT AD/HEALTH & PERFROMANCE
Authorized Official - Prefix:
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVARD
Authorized Official - Suffix:
Authorized Official - Credentials:LAT
Authorized Official - Phone:662-846-4280
Mailing Address - Street 1:1003 W SUNFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38733-0001
Mailing Address - Country:US
Mailing Address - Phone:166-284-6428
Mailing Address - Fax:
Practice Address - Street 1:1003 W SUNFLOWER RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38733-0001
Practice Address - Country:US
Practice Address - Phone:662-846-4280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty