Provider Demographics
NPI:1699259341
Name:RAINEY, JUSTIN EDWARD (LAT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:EDWARD
Last Name:RAINEY
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:MR
Other - First Name:CATO
Other - Middle Name:EDWARD
Other - Last Name:RAINEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAT
Mailing Address - Street 1:308 DOZIER LN
Mailing Address - Street 2:
Mailing Address - City:CALLISBURG
Mailing Address - State:TX
Mailing Address - Zip Code:76240
Mailing Address - Country:US
Mailing Address - Phone:940-665-0961
Mailing Address - Fax:940-665-2849
Practice Address - Street 1:308 DOZIER LN
Practice Address - Street 2:
Practice Address - City:CALLISBURG
Practice Address - State:TX
Practice Address - Zip Code:76240
Practice Address - Country:US
Practice Address - Phone:940-665-0961
Practice Address - Fax:940-665-2849
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT76782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer