Provider Demographics
NPI:1376185637
Name:KIMINKI, MATTHEW RYAN (DPT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RYAN
Last Name:KIMINKI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12040 CASA LINDA CT
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-1884
Mailing Address - Country:US
Mailing Address - Phone:760-345-5453
Mailing Address - Fax:760-345-7063
Practice Address - Street 1:44025 JEFFERSON ST STE 104
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-4874
Practice Address - Country:US
Practice Address - Phone:760-345-5453
Practice Address - Fax:760-345-7063
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT297270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist