Healthcare Provider Details

I. General information

NPI: 1912483439
Provider Name (Legal Business Name): KYEONGHWAN MIN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 MINEOLA BLVD
MINEOLA NY
11501-4006
US

IV. Provider business mailing address

5 EASTERN DR
NEW HYDE PARK NY
11040-3439
US

V. Phone/Fax

Practice location:
  • Phone: 516-366-4321
  • Fax:
Mailing address:
  • Phone: 718-414-3869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number007871
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040583
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: