Healthcare Provider Details

I. General information

NPI: 1396126785
Provider Name (Legal Business Name): SWEET TEAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32416 HUPP DR
TEMECULA CA
92592-1151
US

IV. Provider business mailing address

32416 HUPP DR
TEMECULA CA
92592-1151
US

V. Phone/Fax

Practice location:
  • Phone: 760-212-6785
  • Fax:
Mailing address:
  • Phone: 760-212-6785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NW0100X
TaxonomyWomen's Hospital
License NumberL-59863
License Number StateNY

VIII. Authorized Official

Name: MRS. JENA MARIE REID
Title or Position: LACTATION CONSULTANT
Credential: IBCLC
Phone: 951-382-4722