Provider Demographics
NPI:1881467728
Name:MCNEILLY, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MCNEILLY
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 1:12789 S TALLMAN RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:MI
Mailing Address - Zip Code:48822-9746
Mailing Address - Country:US
Mailing Address - Phone:517-526-2890
Mailing Address - Fax:
Practice Address - Street 1:12789 S TALLMAN RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:MI
Practice Address - Zip Code:48822-9746
Practice Address - Country:US
Practice Address - Phone:517-526-2890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer