Provider Demographics
NPI:1750824389
Name:MYNIHAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MYNIHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 W WELLINGTON AVE
Mailing Address - Street 2:106
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5413
Mailing Address - Country:US
Mailing Address - Phone:419-779-6096
Mailing Address - Fax:
Practice Address - Street 1:528 W WELLINGTON AVE
Practice Address - Street 2:106
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5413
Practice Address - Country:US
Practice Address - Phone:419-779-6096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006996133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered