Healthcare Provider Details

I. General information

NPI: 1760171037
Provider Name (Legal Business Name): JIMMIE SINATRA WARREN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S MARION AVE
LAKE CITY FL
32025-5808
US

IV. Provider business mailing address

201 RACQUET CLUB RD
LELAND MS
38756-3142
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-3016
  • Fax:
Mailing address:
  • Phone: 662-931-3611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: