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General NPI Number Information
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NPI Number | 1821665894
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Entity Type | Individual
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Provider Name | JACK MIXNER MS, ATC
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Gender | Male
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Dates
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Enumeration Date | 06/08/2021
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Last Update Date | 06/08/2021
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Provider Practice Location Address
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Address Line | 1706 E SEMORAN BLVD STE 107
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City | APOPKA
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State | FL
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Zip | 32703-5610
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Country | US
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Telephone | 407-880-7772
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Fax |
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Provider Business Mailing Address
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Address Line | 1788 HEMPEL AVE
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City | WINDERMERE
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State | FL
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Zip | 34786-8118
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Country | US
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Telephone | 407-808-3068
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 5095
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License Number State | FL
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