Healthcare Provider Details

I. General information

NPI: 1245964170
Provider Name (Legal Business Name): SACRED SPACE MIDWIFERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16050 WAYNE ST.
UNION MI
49130
US

IV. Provider business mailing address

16050 WAYNE ST.
UNION MI
49130
US

V. Phone/Fax

Practice location:
  • Phone: 574-248-2485
  • Fax: 574-319-7689
Mailing address:
  • Phone: 574-248-2485
  • Fax: 574-319-7689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHANNON STAR GARRIES
Title or Position: OWNER/PRESIDENT
Credential: LM
Phone: 574-248-2485