Healthcare Provider Details

I. General information

NPI: 1093169138
Provider Name (Legal Business Name): KIMBERLY S MINER LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH LATHAM STREET SUITE 103B
SANDWICH IL
60548
US

IV. Provider business mailing address

100 SOUTH LATHAM STREET SUITE 103B
SANDWICH IL
60548
US

V. Phone/Fax

Practice location:
  • Phone: 815-508-8635
  • Fax:
Mailing address:
  • Phone: 815-508-8635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198.001263
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: