Provider Demographics
NPI:1275692824
Name:MINERVINI, KIM R (PT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:R
Last Name:MINERVINI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:R
Other - Last Name:SOSCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:79 BEARFORT RD
Mailing Address - Street 2:
Mailing Address - City:WEST MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07480-1401
Mailing Address - Country:US
Mailing Address - Phone:973-903-3346
Mailing Address - Fax:
Practice Address - Street 1:104 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2502
Practice Address - Country:US
Practice Address - Phone:201-493-8111
Practice Address - Fax:201-493-8279
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00792200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ063795S04Medicare PIN