MEDICARE: JONATHAN HINES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist		TX
2	2255A2300X	Athletic Trainer		TX

General Provider Information

NPI Number	:	1164193371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN HINES

Provider Business Mailing Address
First Line	:	1913 WILLOW BEND DR
Second Line	:
City	:	RED OAK
State	:	TX
Zip	:	75154-3871
Country	:	US
Telephone Number	:	214-815-7006
Fax Number	:

Provider Business Practice Location Address
First Line	:	1913 WILLOW BEND DR
Second Line	:
City	:	RED OAK
State	:	TX
Zip	:	75154-3871
Country	:	US
Telephone Number	:	214-815-7006
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2021
Last Update Date	:	10/05/2021

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Directions to “ JONATHAN HINES ” Practice Location

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