Healthcare Provider Details

I. General information

NPI: 1699067728
Provider Name (Legal Business Name): KIMBERLY AMELIA MINICK DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2011
Last Update Date: 05/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 E MAIN ST
CANTON GA
30114-2708
US

IV. Provider business mailing address

191 E MAIN ST
CANTON GA
30114-2708
US

V. Phone/Fax

Practice location:
  • Phone: 770-757-3831
  • Fax:
Mailing address:
  • Phone: 770-757-3831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR008433
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberCHIR008433
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License NumberCHIR008433
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR008433
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIR008433
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License NumberCHIR008433
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: