Provider Demographics
NPI:1962091835
Name:WARE, JUSTIN KEITH (ATC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:KEITH
Last Name:WARE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 HAPPY LN
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-9634
Mailing Address - Country:US
Mailing Address - Phone:662-820-0801
Mailing Address - Fax:
Practice Address - Street 1:900 SISK AVENUE EXTENDED STE C
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-3433
Practice Address - Country:US
Practice Address - Phone:662-449-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT-07082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer