Healthcare Provider Details

I. General information

NPI: 1558473579
Provider Name (Legal Business Name): MICHAEL GARY MINOR RKT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 IRVING ST NW
WASHINGTON DC
20422-0001
US

IV. Provider business mailing address

802 JAMES RIDGE RD
BOWIE MD
20721-7283
US

V. Phone/Fax

Practice location:
  • Phone: 202-745-8618
  • Fax:
Mailing address:
  • Phone: 301-218-8019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number1532
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: