Provider Demographics
NPI:1275288391
Name:MAMA MENTOR LLC
Entity Type:Organization
Organization Name:MAMA MENTOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RLC, IBCLC
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:RLC, IBCLC
Authorized Official - Phone:706-814-8083
Mailing Address - Street 1:175 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-1391
Mailing Address - Country:US
Mailing Address - Phone:706-814-8083
Mailing Address - Fax:
Practice Address - Street 1:175 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-1391
Practice Address - Country:US
Practice Address - Phone:706-814-8083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty