Provider Demographics
NPI:1750863957
Name:MCNEESE STATE UNIVERSITY
Entity Type:Organization
Organization Name:MCNEESE STATE UNIVERSITY
Other - Org Name:MCNEESE SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MOUZON
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:972-367-4845
Mailing Address - Street 1:15305 DALLAS PKWY STE 800
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 E MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-5832
Practice Address - Country:US
Practice Address - Phone:972-367-4845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-04
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty