MEDICARE: DR. KIMBERLY AMELIA MINICK DC

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
2	111NN1001X	Nutrition Chiropractor	CHIR008433	GA
3	111NP0017X	Pediatric Chiropractor	CHIR008433	GA
4	111NR0400X	Rehabilitation Chiropractor	CHIR008433	GA
5	111NS0005X	Sports Physician Chiropractor	CHIR008433	GA
6	111NX0100X	Occupational Health Chiropractor	CHIR008433	GA

General Provider Information

NPI Number	:	1699067728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY AMELIA MINICK DC

Provider Business Mailing Address
First Line	:	191 E MAIN ST
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-2708
Country	:	US
Telephone Number	:	770-757-3831
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 E MAIN ST
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-2708
Country	:	US
Telephone Number	:	770-757-3831
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2011
Last Update Date	:	05/08/2011

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