Provider Demographics
NPI:1700419249
Name:MAHOGANY MATERNITY
Entity Type:Organization
Organization Name:MAHOGANY MATERNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:CD(DONA) CLS, LCCE
Authorized Official - Phone:574-383-1743
Mailing Address - Street 1:22500 LINCOLN WAY WEST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628
Mailing Address - Country:US
Mailing Address - Phone:574-383-1743
Mailing Address - Fax:
Practice Address - Street 1:22500 LINCOLN WAY WEST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628
Practice Address - Country:US
Practice Address - Phone:574-383-1743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty