MEDICARE: SACRED ENTRANCE MIDWIFERY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife	201	CA

General Provider Information

NPI Number	:	1093916694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED ENTRANCE MIDWIFERY SERVICES

Provider Business Mailing Address
First Line	:	11965 VENICE BLVD
Second Line	:	SUITE# 204
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-3979
Country	:	US
Telephone Number	:	310-566-7690
Fax Number	:	310-566-7699

Provider Business Practice Location Address
First Line	:	11965 VENICE BLVD
Second Line	:	SUITE# 204
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-3979
Country	:	US
Telephone Number	:	310-566-7690
Fax Number	:	310-566-7699

Authorized Official
Title or Position	:	OWNER
Name	:	ALEKSANDRA EVANGUEULIDI
Credential	:	L.M., CPM
Telephone Number	:	310-566-7690

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	12/09/2010

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