Provider Demographics
NPI:1649341272
Name:MISSOURI STATE UNIVERSITY ATHLETIC MEDICAL AND REHABILITATION SERVICES
Entity type:Organization
Organization Name:MISSOURI STATE UNIVERSITY ATHLETIC MEDICAL AND REHABILITATION SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PENKALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:417-836-5461
Mailing Address - Street 1:901 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65897-0027
Mailing Address - Country:US
Mailing Address - Phone:417-836-5461
Mailing Address - Fax:417-836-6101
Practice Address - Street 1:901 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65897-0027
Practice Address - Country:US
Practice Address - Phone:417-836-5461
Practice Address - Fax:417-836-6101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center