Healthcare Provider Details

I. General information

NPI: 1215731096
Provider Name (Legal Business Name): MGM PROFESSIONAL CARE SERVICES LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 NEW YORK AVE
FREEPORT NY
11520-1538
US

IV. Provider business mailing address

134 NEW YORK AVE
FREEPORT NY
11520-1538
US

V. Phone/Fax

Practice location:
  • Phone: 646-416-3820
  • Fax:
Mailing address:
  • Phone: 646-416-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State

VIII. Authorized Official

Name: MARTHA GEORGE MARCELLUS
Title or Position: LACTATION CONSULTANT
Credential: RN, IBCLC, CLC
Phone: 646-416-3820