Provider Demographics
NPI:1194480855
Name:JUSTICE, MASON CHRISTIAN (AS)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:CHRISTIAN
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SHORT ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45308-1159
Mailing Address - Country:US
Mailing Address - Phone:937-670-2289
Mailing Address - Fax:
Practice Address - Street 1:28100 TORCH PKWY STE 600
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-4030
Practice Address - Country:US
Practice Address - Phone:630-413-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation