Healthcare Provider Details

I. General information

NPI: 1023957966
Provider Name (Legal Business Name): MYRA GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 W 22ND ST STE 23
OAK BROOK IL
60523-1237
US

IV. Provider business mailing address

2603 W 22ND ST
OAK BROOK IL
60523-1213
US

V. Phone/Fax

Practice location:
  • Phone: 630-629-2700
  • Fax: 866-243-5066
Mailing address:
  • Phone: 630-629-2700
  • Fax: 866-243-5066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: