MEDICARE: MR. JUSTIN WAYNE MCKINNEY MS, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		TN

General Provider Information

NPI Number	:	1003845348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN WAYNE MCKINNEY MS, ATC

Provider Business Mailing Address
First Line	:	102 BENT TREE CT
Second Line	:
City	:	LEBANON
State	:	TN
Zip	:	37087-2057
Country	:	US
Telephone Number	:	615-453-8262
Fax Number	:

Provider Business Practice Location Address
First Line	:	1616 W MAIN ST
Second Line	:
City	:	LEBANON
State	:	TN
Zip	:	37087-3100
Country	:	US
Telephone Number	:	615-443-6818
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	07/08/2007

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