MEDICARE: BIRTH BUNGALOW, LLC

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		CT
2	174N00000X	Lactation Consultant (Non-RN)	L-24523	CA

General Provider Information

NPI Number	:	1578969424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRTH BUNGALOW, LLC

Provider Business Mailing Address
First Line	:	1 BROAD ST UNIT 16F
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06901-2334
Country	:	US
Telephone Number	:	203-614-9030
Fax Number	:	310-872-1533

Provider Business Practice Location Address
First Line	:	1 BROAD ST UNIT 16F
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06901-2334
Country	:	US
Telephone Number	:	203-614-9030
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICOLE PELUSO
Credential	:	IBCLC
Telephone Number	:	203-614-9030

Provider Enumeration Date	:	11/04/2014
Last Update Date	:	05/04/2026

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Directions to “BIRTH BUNGALOW, LLC ” Practice Location

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