Healthcare Provider Details

I. General information

NPI: 1780479246
Provider Name (Legal Business Name): WILD ZEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2379 N BAILEY RD
CORAL MI
49322-9754
US

IV. Provider business mailing address

2379 N BAILEY RD
CORAL MI
49322-9754
US

V. Phone/Fax

Practice location:
  • Phone: 616-648-0444
  • Fax:
Mailing address:
  • Phone: 616-648-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: CARRIE L LABARGE
Title or Position: DOULA
Credential: DOULA, CBS, LCE, RYT
Phone: 616-648-0444