Healthcare Provider Details

I. General information

NPI: 1104654334
Provider Name (Legal Business Name): MENDED & MADE WELL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9211 AMYS ST APT 30
SPRING VALLEY CA
91977-3992
US

IV. Provider business mailing address

9211 AMYS ST APT 30
SPRING VALLEY CA
91977-3992
US

V. Phone/Fax

Practice location:
  • Phone: 619-302-8691
  • Fax:
Mailing address:
  • Phone: 619-302-8691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: MS. LATRICE MARIE REID
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: IBCLC
Phone: 619-302-8691