Provider Demographics
NPI:1659471522
Name:MINNICK, JEREMY ARTHUR (LMT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:ARTHUR
Last Name:MINNICK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 NW 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-3101
Mailing Address - Country:US
Mailing Address - Phone:239-671-9900
Mailing Address - Fax:239-772-0146
Practice Address - Street 1:2143 NW 17TH AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33993-3101
Practice Address - Country:US
Practice Address - Phone:239-671-9900
Practice Address - Fax:239-772-0146
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 25921225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC3738OtherBCBS OF FL.