Basic Information
| Provider Information | |||||||||
| NPI: | 1821675364 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINNICK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 OVERLOOK BLVD | ||||||||
| Address2: | |||||||||
| City: | STRUTHERS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444711615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302722759 | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 BLOSSOM LN | ||||||||
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| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444604284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303373033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2021 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OTA007496 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.