Healthcare Provider Details

I. General information

NPI: 1477003614
Provider Name (Legal Business Name): OTHER SIDE LACTATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4838 E GLENN ST
TUCSON AZ
85712-1237
US

IV. Provider business mailing address

4838 E GLENN ST
TUCSON AZ
85712-1237
US

V. Phone/Fax

Practice location:
  • Phone: 520-349-7745
  • Fax:
Mailing address:
  • Phone: 520-349-7745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number StateAZ

VIII. Authorized Official

Name: CHRISTINA BLAKE
Title or Position: OWNER
Credential: RN, IBCLC
Phone: 520-349-7745