Provider Demographics
NPI:1053783332
Name:BLOOM WATERBIRTH AND WELLNESS CENTER
Entity type:Organization
Organization Name:BLOOM WATERBIRTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER AND LICENSED MIDWIFE
Authorized Official - Prefix:MS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:LM
Authorized Official - Phone:707-671-7476
Mailing Address - Street 1:530 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4926
Mailing Address - Country:US
Mailing Address - Phone:707-671-7476
Mailing Address - Fax:707-671-7478
Practice Address - Street 1:530 S MAIN ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4926
Practice Address - Country:US
Practice Address - Phone:707-671-7476
Practice Address - Fax:707-671-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA263261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing