MEDICARE: THE MINICK CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIR008433	GA

General Provider Information

NPI Number	:	1558656975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MINICK CLINIC LLC

Provider Business Mailing Address
First Line	:	191 E MAIN ST
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-2708
Country	:	US
Telephone Number	:	678-880-8720
Fax Number	:	678-880-6201

Provider Business Practice Location Address
First Line	:	191 E MAIN ST
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-2708
Country	:	US
Telephone Number	:	678-880-8720
Fax Number	:	678-880-6201

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KIMBERLY AMELIA MINICK
Credential	:	DC
Telephone Number	:	678-880-8720

Provider Enumeration Date	:	06/14/2011
Last Update Date	:	06/14/2011

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Directions to “THE MINICK CLINIC LLC ” Practice Location

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