MEDICARE: DIVINITY BIRTH SERVICES, 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	302F00000X	Exclusive Provider Organization	133-49	WI

General Provider Information

NPI Number	:	1841697992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINITY BIRTH SERVICES, LLC

Provider Business Mailing Address
First Line	:	3074 OAK ST
Second Line	:
City	:	COTTAGE GROVE
State	:	WI
Zip	:	53527-9511
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3074 OAK ST
Second Line	:
City	:	COTTAGE GROVE
State	:	WI
Zip	:	53527-9511
Country	:	US
Telephone Number	:	608-469-1879
Fax Number	:

Authorized Official
Title or Position	:	OWNER, LICENSED MIDWIFE
Name	:	MISS DANIELLE K HAUGE
Credential	:	CPM, LM
Telephone Number	:	608-469-1879

Provider Enumeration Date	:	12/03/2014
Last Update Date	:	12/03/2014

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