=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154189017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MGM LACTATION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2024
-----------------------------------------------------
Last Update Date | 03/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 S ORANGE GROVE BLVD APT 6
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105-3352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-683-3247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 S ORANGE GROVE BLVD APT 6
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105-3352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-683-3247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MIRLO MCALISTER
-----------------------------------------------------
Credential | RN, PHN, IBCLC
-----------------------------------------------------
Telephone | 310-683-3247
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------