Provider Demographics
NPI:1053617696
Name:TREE OF LIFE BIRTH AND GYNECOLOGY
Entity type:Organization
Organization Name:TREE OF LIFE BIRTH AND GYNECOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KALEEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, CNM
Authorized Official - Phone:407-929-6599
Mailing Address - Street 1:165 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714
Mailing Address - Country:US
Mailing Address - Phone:407-878-2757
Mailing Address - Fax:407-288-8530
Practice Address - Street 1:165 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714
Practice Address - Country:US
Practice Address - Phone:407-878-2757
Practice Address - Fax:407-288-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-30
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QB0400X
FL9170873367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthingGroup - Single Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111617800Medicaid
FL1922156330Medicaid