Provider Demographics
NPI:1861950545
Name:TERESA MCCORMACK LACTATION SUPPORT LLC
Entity type:Organization
Organization Name:TERESA MCCORMACK LACTATION SUPPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:RN, IBCLC
Authorized Official - Phone:858-216-6257
Mailing Address - Street 1:9728 MARILLA DR UNIT 205
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-2853
Mailing Address - Country:US
Mailing Address - Phone:858-216-6257
Mailing Address - Fax:
Practice Address - Street 1:4443 30TH ST STE 205
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4291
Practice Address - Country:US
Practice Address - Phone:619-567-8146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty