=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447844030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREASTFEEDING SUPPORT & WELLNESS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2021
-----------------------------------------------------
Last Update Date | 04/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 576 ROMENCE RD STE 124
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-3436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-205-1385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3734 BELLFLOWER DR
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-3970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-205-1385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LINDA DYER-ERTL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-205-1385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------