Healthcare Provider Details

I. General information

NPI: 1457502155
Provider Name (Legal Business Name): MARVELOUS MILK SUPPLIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BURNHAM ST
RICHLAND CENTER WI
53581-2402
US

IV. Provider business mailing address

101 BURNHAM ST
RICHLAND CENTER WI
53581-2402
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-8124
  • Fax:
Mailing address:
  • Phone: 608-647-8124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number1769-029
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number100-16303
License Number StateWI

VIII. Authorized Official

Name: MRS. MARY J COLEMAN
Title or Position: LACTATION CONSULTANT
Credential: IBCLC
Phone: 608-647-8124