Provider Demographics
NPI:1881183630
Name:MINNICK, KEVIN RAY (DPT)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RAY
Last Name:MINNICK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 SW BLUE PKWY
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-3805
Mailing Address - Country:US
Mailing Address - Phone:816-272-1427
Mailing Address - Fax:
Practice Address - Street 1:806 SW BLUE PKWY
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-3805
Practice Address - Country:US
Practice Address - Phone:816-272-1427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012027753208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation