Healthcare Provider Details

I. General information

NPI: 1275901811
Provider Name (Legal Business Name): JONATHAN WARREN L.P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

574 E MAIN ST
INDEPENDENCE VA
24348-3879
US

IV. Provider business mailing address

574 E MAIN ST
INDEPENDENCE VA
24348-3879
US

V. Phone/Fax

Practice location:
  • Phone: 276-773-8118
  • Fax: 276-773-2219
Mailing address:
  • Phone: 276-773-8118
  • Fax: 276-773-2219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604204
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: