Healthcare Provider Details

I. General information

NPI: 1871370569
Provider Name (Legal Business Name): ANCESTRAL LACTATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14621 VAN NUYS PL
PANORAMA CITY CA
91402-1024
US

IV. Provider business mailing address

14621 VAN NUYS PL
PANORAMA CITY CA
91402-1024
US

V. Phone/Fax

Practice location:
  • Phone: 818-747-4292
  • Fax:
Mailing address:
  • Phone: 818-747-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: MIREYA GONZALEZ
Title or Position: EXECUTIVE DIRECTOR
Credential: MPH, IBCLC
Phone: 818-747-4292