MEDICARE: TERESITA DE JESUS VENEGAS IBCLC

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	174N00000X	Lactation Consultant (Non-RN)	11193227	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11193227	OTHER	CA	IBCLC

General Provider Information

NPI Number	:	1437497641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESITA DE JESUS VENEGAS IBCLC

Provider Business Mailing Address
First Line	:	3918 E 6TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-1902
Country	:	US
Telephone Number	:	323-266-0287
Fax Number	:

Provider Business Practice Location Address
First Line	:	3918 E 6TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-1902
Country	:	US
Telephone Number	:	323-266-0287
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2013
Last Update Date	:	01/23/2013

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