Provider Demographics
NPI:1629664313
Name:MOMOLOGY MATERNAL WELLNESS CLUB
Entity Type:Organization
Organization Name:MOMOLOGY MATERNAL WELLNESS CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-2036
Mailing Address - Street 1:4614 DOHN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-2902
Mailing Address - Country:US
Mailing Address - Phone:502-354-8424
Mailing Address - Fax:502-632-1432
Practice Address - Street 1:4614 DOHN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2902
Practice Address - Country:US
Practice Address - Phone:502-354-8424
Practice Address - Fax:502-632-1432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health