Provider Demographics
NPI:1558026385
Name:WELLSPRING LACTATION LLC
Entity Type:Organization
Organization Name:WELLSPRING LACTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:BOUSU
Authorized Official - Suffix:
Authorized Official - Credentials:RN IBCLC
Authorized Official - Phone:763-342-1752
Mailing Address - Street 1:558 KAYLA LN
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55341-4504
Mailing Address - Country:US
Mailing Address - Phone:763-342-1752
Mailing Address - Fax:
Practice Address - Street 1:558 KAYLA LN
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MN
Practice Address - Zip Code:55341-4504
Practice Address - Country:US
Practice Address - Phone:877-840-2143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service