Healthcare Provider Details

I. General information

NPI: 1578969424
Provider Name (Legal Business Name): BIRTH BUNGALOW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 HILL RD
GREENWICH CT
06830-4043
US

IV. Provider business mailing address

34 HILL ROAD
GREENWICH CT
06830
US

V. Phone/Fax

Practice location:
  • Phone: 323-595-4006
  • Fax:
Mailing address:
  • Phone: 323-595-4006
  • Fax: 310-872-1533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-24523
License Number StateCA

VIII. Authorized Official

Name: NICOLE PELUSO
Title or Position: PRESIDENT
Credential: IBCLC
Phone: 323-595-4006