Provider Demographics
NPI:1578969424
Name:BIRTH BUNGALOW, LLC
Entity Type:Organization
Organization Name:BIRTH BUNGALOW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PELUSO
Authorized Official - Suffix:
Authorized Official - Credentials:IBCLC
Authorized Official - Phone:323-595-4006
Mailing Address - Street 1:34 HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830
Mailing Address - Country:US
Mailing Address - Phone:323-595-4006
Mailing Address - Fax:310-872-1533
Practice Address - Street 1:34 HILL RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4043
Practice Address - Country:US
Practice Address - Phone:323-595-4006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-24523174N00000X
CT176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Single Specialty