Provider Demographics
NPI:1740171479
Name:LOVE, MYNNYCONJOU THOMAS
Entity type:Individual
Prefix:
First Name:MYNNYCONJOU
Middle Name:THOMAS
Last Name:LOVE
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 1:1094 IRONGATE LN APT D
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-4169
Mailing Address - Country:US
Mailing Address - Phone:614-625-0663
Mailing Address - Fax:
Practice Address - Street 1:1094 IRONGATE LN APT D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4169
Practice Address - Country:US
Practice Address - Phone:614-625-0663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRU721109343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)