=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982528972
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYSTICAL RISINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2026
-----------------------------------------------------
Last Update Date | 08/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 908 BURLINGTON DR
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95356-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-204-3103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 908 BURLINGTON DR
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95356-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-204-3103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOULA
-----------------------------------------------------
Name | MS. ROSE A WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-204-3103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374J00000X
-----------------------------------------------------
Taxonomy Name | Doula
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------