Healthcare Provider Details

I. General information

NPI: 1790085942
Provider Name (Legal Business Name): THE SANCTUARY BIRTH & FAMILY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11965 VENICE BLVD SUITE 307
LOS ANGELES CA
90066-3979
US

IV. Provider business mailing address

11965 VENICE BLVD SUITE 307
LOS ANGELES CA
90066-3979
US

V. Phone/Fax

Practice location:
  • Phone: 310-566-7690
  • Fax: 310-566-7699
Mailing address:
  • Phone: 310-566-7690
  • Fax: 310-566-7699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number201
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEKSANDRA EVANGUELIDI
Title or Position: CO-OWNER
Credential: LM, CPM
Phone: 310-566-7690