Provider Demographics
NPI:1538581459
Name:WINGATE UNIVERSITY
Entity type:Organization
Organization Name:WINGATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GRADUATE ASSISTANT ATHLETIC TRAINER
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRODECKI
Authorized Official - Suffix:
Authorized Official - Credentials:AT
Authorized Official - Phone:847-650-0295
Mailing Address - Street 1:220 N CAMDEN RD
Mailing Address - Street 2:P.O. BOX 5002
Mailing Address - City:WINGATE
Mailing Address - State:NC
Mailing Address - Zip Code:28174-9644
Mailing Address - Country:US
Mailing Address - Phone:704-233-8165
Mailing Address - Fax:
Practice Address - Street 1:220 N CAMDEN RD
Practice Address - Street 2:
Practice Address - City:WINGATE
Practice Address - State:NC
Practice Address - Zip Code:28174-9644
Practice Address - Country:US
Practice Address - Phone:704-233-8165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-12
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20000077062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty