Healthcare Provider Details

I. General information

NPI: 1336075449
Provider Name (Legal Business Name): KYUNGJUN MIN PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RYAN MIN PT, DPT, CSCS

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61
CRYSTAL CTY MO
63028-4100
US

IV. Provider business mailing address

1634 S RAFORD DR
SPRINGFIELD MO
65809-2336
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-1606
  • Fax: 636-933-1871
Mailing address:
  • Phone: 417-655-6659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2024032573
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: