MEDICARE: MR. RYAN P MINICK MPT

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	225100000X	Physical Therapist	10305	NC

General Provider Information

NPI Number	:	1730146812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN P MINICK MPT

Provider Business Mailing Address
First Line	:	2117 LOMBARDY CIR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28203-6061
Country	:	US
Telephone Number	:	704-996-2030
Fax Number	:

Provider Business Practice Location Address
First Line	:	1809 EAST BLVD
Second Line	:	SUITE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28203-5879
Country	:	US
Telephone Number	:	704-374-1811
Fax Number	:

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

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	07/08/2007

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