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General NPI Number Information
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NPI Number | 1558656975
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Entity Type | Organization
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Legal Business Name | THE MINICK CLINIC LLC
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Dates
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Enumeration Date | 06/14/2011
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Last Update Date | 06/14/2011
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Provider Practice Location Address
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Address Line | 191 E MAIN ST
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City | CANTON
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State | GA
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Zip | 30114-2708
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Country | US
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Telephone | 678-880-8720
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Fax | 678-880-6201
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Provider Business Mailing Address
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Address Line | 191 E MAIN ST
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City | CANTON
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State | GA
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Zip | 30114-2708
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Country | US
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Telephone | 678-880-8720
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Fax | 678-880-6201
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Authorized Official
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Title or Position | OWNER
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Name | DR. KIMBERLY AMELIA MINICK
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Credential | DC
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Telephone | 678-880-8720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIR008433
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License Number State | GA
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