MEDICARE: TOURMALINE BIRTH AND WELLNESS COLLECTIVE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife

General Provider Information

NPI Number	:	1043859168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOURMALINE BIRTH AND WELLNESS COLLECTIVE

Provider Business Mailing Address
First Line	:	4545 FANUEL ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-2904
Country	:	US
Telephone Number	:	714-585-6197
Fax Number	:

Provider Business Practice Location Address
First Line	:	4545 FANUEL ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-2904
Country	:	US
Telephone Number	:	714-585-6197
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. MARAL SHABAK
Credential	:	LM, CPM
Telephone Number	:	714-585-6197

Provider Enumeration Date	:	01/06/2020
Last Update Date	:	01/06/2020

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Directions to “TOURMALINE BIRTH AND WELLNESS COLLECTIVE ” Practice Location

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