Provider Demographics
NPI:1790576957
Name:MY MOM GLOW LLC
Entity type:Organization
Organization Name:MY MOM GLOW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LOBAINA
Authorized Official - Suffix:
Authorized Official - Credentials:LM,CPM,IBCLC
Authorized Official - Phone:305-600-8109
Mailing Address - Street 1:320 SW 67TH TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33023-1274
Mailing Address - Country:US
Mailing Address - Phone:305-600-8109
Mailing Address - Fax:
Practice Address - Street 1:2750 N 29TH AVE STE 309
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-1521
Practice Address - Country:US
Practice Address - Phone:954-880-1182
Practice Address - Fax:954-301-8385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty