Provider Demographics
NPI:1093169138
Name:MINER, KIMBERLY S (LAC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:S
Last Name:MINER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SOUTH LATHAM STREET
Mailing Address - Street 2:SUITE 103B
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548
Mailing Address - Country:US
Mailing Address - Phone:815-508-8635
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTH LATHAM STREET
Practice Address - Street 2:SUITE 103B
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548
Practice Address - Country:US
Practice Address - Phone:815-508-8635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001263171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist