Provider Demographics
NPI:1457502155
Name:MARVELOUS MILK SUPPLIES
Entity Type:Organization
Organization Name:MARVELOUS MILK SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LACTATION CONSULTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:IBCLC
Authorized Official - Phone:608-647-8124
Mailing Address - Street 1:101 BURNHAM ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-2402
Mailing Address - Country:US
Mailing Address - Phone:608-647-8124
Mailing Address - Fax:
Practice Address - Street 1:101 BURNHAM ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-2402
Practice Address - Country:US
Practice Address - Phone:608-647-8124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDELA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100-16303174400000X
WI1769-029251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251K00000XAgenciesPublic Health or Welfare
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41699100Medicare UPIN