Healthcare Provider Details

I. General information

NPI: 1124585120
Provider Name (Legal Business Name): VANESSA MIHALICK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HOBART ST
CADILLAC MI
49601-2331
US

IV. Provider business mailing address

13307 W SHORE DR
HOUGHTON LAKE MI
48629-8656
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-6633
  • Fax:
Mailing address:
  • Phone: 248-496-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86051661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: