=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417704834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIA LACTEA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2024
-----------------------------------------------------
Last Update Date | 05/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 146 S LAKEVIEW DR
-----------------------------------------------------
City | GIBBSBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08026-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-248-0205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 ROLLINGWOOD DR
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-2811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-669-1407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KARA M. THORNTON
-----------------------------------------------------
Credential | IBCLC
-----------------------------------------------------
Telephone | 856-669-1407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174N00000X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Non-RN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------