Provider Demographics
NPI:1134791718
Name:MCKIE, MININA (LDO)
Entity type:Individual
Prefix:
First Name:MININA
Middle Name:
Last Name:MCKIE
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4526 SW 179TH WAY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-6306
Mailing Address - Country:US
Mailing Address - Phone:954-319-8468
Mailing Address - Fax:
Practice Address - Street 1:1860 N PINE ISLAND RD STE 105
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-5234
Practice Address - Country:US
Practice Address - Phone:754-216-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4049156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty