Healthcare Provider Details

I. General information

NPI: 1548626088
Provider Name (Legal Business Name): JOHN MICHAEL MINEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2299 PEARL ST STE 105
BOULDER CO
80302-4669
US

IV. Provider business mailing address

3260 CRIPPLE CREEK TRL
BOULDER CO
80305-7194
US

V. Phone/Fax

Practice location:
  • Phone: 303-736-9343
  • Fax: 855-667-9565
Mailing address:
  • Phone: 330-421-4237
  • Fax: 855-667-9565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIR009623
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHR.0007584
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: