=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245741651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHIGAN BORN AND RAISED LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2017
-----------------------------------------------------
Last Update Date | 10/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2932 CHICAGO DR SW
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-1176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-557-7118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19702 MAPLE AVE
-----------------------------------------------------
City | CONKLIN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49403-9562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-557-7118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER/HEALTH EDUCATOR
-----------------------------------------------------
Name | MS. AMANDA KRISTIN GARVEY
-----------------------------------------------------
Credential | MPH, EMT
-----------------------------------------------------
Telephone | 231-557-7118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174N00000X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Non-RN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 176B00000X
-----------------------------------------------------
Taxonomy Name | Midwife
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 374J00000X
-----------------------------------------------------
Taxonomy Name | Doula
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------