Healthcare Provider Details

I. General information

NPI: 1164742862
Provider Name (Legal Business Name): RICKEY DEON MINOR MA, PLPC, ED, D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST
SAINT LOUIS MO
63103-2303
US

IV. Provider business mailing address

1340 PARTRIDGE AVE
SAINT LOUIS MO
63130-1943
US

V. Phone/Fax

Practice location:
  • Phone: 314-651-0921
  • Fax:
Mailing address:
  • Phone: 314-854-5737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: