Healthcare Provider Details

I. General information

NPI: 1659424455
Provider Name (Legal Business Name): JIMMIE LEE MASK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 MEMORIAL BLVD N
MARTINSVILLE VA
24112-2418
US

IV. Provider business mailing address

825 MEMORIAL BLVD N
MARTINSVILLE VA
24112-2418
US

V. Phone/Fax

Practice location:
  • Phone: 276-632-8385
  • Fax: 276-632-9736
Mailing address:
  • Phone: 276-632-8385
  • Fax: 276-632-9736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0000158
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number00002247
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: