MEDICARE: SACRED SPACE MIDWIFERY

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
2	261QB0400X	Birthing Clinic/Center

General Provider Information

NPI Number	:	1245964170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED SPACE MIDWIFERY

Provider Business Mailing Address
First Line	:	16050 WAYNE ST.
Second Line	:
City	:	UNION
State	:	MI
Zip	:	49130
Country	:	US
Telephone Number	:	574-248-2485
Fax Number	:	574-319-7689

Provider Business Practice Location Address
First Line	:	16050 WAYNE ST.
Second Line	:
City	:	UNION
State	:	MI
Zip	:	49130
Country	:	US
Telephone Number	:	574-248-2485
Fax Number	:	574-319-7689

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	SHANNON STAR GARRIES
Credential	:	LM
Telephone Number	:	574-248-2485

Provider Enumeration Date	:	07/15/2022
Last Update Date	:	07/15/2022

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Directions to “SACRED SPACE MIDWIFERY ” Practice Location

Language	Start Address	Practice Location

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