=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619188356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JIMMIE L. MASK, D.C., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 MEMORIAL BLVD N
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-632-8385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 825 MEMORIAL BLVD N
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-632-8385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JIMMIE L. MASK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 276-632-8385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104000158
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------