Provider Demographics
NPI:1790175628
Name:BRIGHAM YOUNG UNIVERSITY
Entity Type:Organization
Organization Name:BRIGHAM YOUNG UNIVERSITY
Other - Org Name:BYU DANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position: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 1:5050 SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3995
Mailing Address - Country:US
Mailing Address - Phone:972-367-4845
Mailing Address - Fax:972-367-3452
Practice Address - Street 1:173 RICHARDS BUILDING
Practice Address - Street 2:DANCE DEPARTMENT
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602-2000
Practice Address - Country:US
Practice Address - Phone:972-367-4845
Practice Address - Fax:972-367-3452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty