MEDICARE: AUTHENTIC BIRTH CENTER . WELLNESS COLLECTIVE, 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	261QB0400X	Birthing Clinic/Center		WI

General Provider Information

NPI Number	:	1669807707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTHENTIC BIRTH CENTER . WELLNESS COLLECTIVE, LLC

Provider Business Mailing Address
First Line	:	530 N 108TH PL
Second Line	:	SUITE 100
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-4253
Country	:	US
Telephone Number	:	414-559-2229
Fax Number	:

Provider Business Practice Location Address
First Line	:	530 N 108TH PL
Second Line	:	SUITE 100
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-4253
Country	:	US
Telephone Number	:	414-559-2229
Fax Number	:

Authorized Official
Title or Position	:	OWNER,
Name	:	MRS. LANETTE JOY MCQUITTY
Credential	:	LM, CPM
Telephone Number	:	414-559-2229

Provider Enumeration Date	:	09/09/2013
Last Update Date	:	09/09/2013

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