Provider Demographics
NPI:1558503433
Name:CENTRAL METHODIST UNIVERSITY SPORTS MEDICINE/ATHLETIC TRAINING
Entity type:Organization
Organization Name:CENTRAL METHODIST UNIVERSITY SPORTS MEDICINE/ATHLETIC TRAINING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR,SPORTS MED/ATH TRAINING
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELTON
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:660-248-6217
Mailing Address - Street 1:411 CENTRAL METHODIST SQ
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MO
Mailing Address - Zip Code:65248-1104
Mailing Address - Country:US
Mailing Address - Phone:660-248-6217
Mailing Address - Fax:660-248-6381
Practice Address - Street 1:411 CENTRAL METHODIST SQ
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1104
Practice Address - Country:US
Practice Address - Phone:660-248-6217
Practice Address - Fax:660-248-6381
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL METHODIST UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1024372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty