MEDICARE: MIA KORINNE ROETHERFORD

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)	L112282	MI

General Provider Information

NPI Number	:	1477058394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA KORINNE ROETHERFORD

Provider Business Mailing Address
First Line	:	18697 SUNDERLAND RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-2816
Country	:	US
Telephone Number	:	313-587-0497
Fax Number	:

Provider Business Practice Location Address
First Line	:	18697 SUNDERLAND RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-2816
Country	:	US
Telephone Number	:	313-587-0497
Fax Number	:

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

Provider Enumeration Date	:	03/25/2018
Last Update Date	:	03/25/2018

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Directions to “ MIA KORINNE ROETHERFORD ” Practice Location

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