Provider Demographics
NPI:1891038303
Name:MISSISSIPPI STATE UNIVERSITY
Entity Type:Organization
Organization Name:MISSISSIPPI STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:662-325-1028
Mailing Address - Street 1:325 HARDY ROAD
Mailing Address - Street 2:
Mailing Address - City:MISSISSIPPI STATE
Mailing Address - State:MS
Mailing Address - Zip Code:39762-0721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 HARDY ROAD
Practice Address - Street 2:
Practice Address - City:MISSISSIPPI STATE
Practice Address - State:MS
Practice Address - Zip Code:39762-9736
Practice Address - Country:US
Practice Address - Phone:662-325-1028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2774261QC1500X, 261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health