Provider Demographics
NPI:1083072060
Name:MOUNTAIN SEA MIDWIFERY AND WELLNESS
Entity Type:Organization
Organization Name:MOUNTAIN SEA MIDWIFERY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MIDWIFE
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:FORBES
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, CDM, BSM
Authorized Official - Phone:907-299-5669
Mailing Address - Street 1:PO BOX 15024
Mailing Address - Street 2:
Mailing Address - City:FRITZ CREEK
Mailing Address - State:AK
Mailing Address - Zip Code:99603
Mailing Address - Country:US
Mailing Address - Phone:907-299-5669
Mailing Address - Fax:907-782-4394
Practice Address - Street 1:53254 MERIMAC
Practice Address - Street 2:
Practice Address - City:FRITZ CREEK
Practice Address - State:AK
Practice Address - Zip Code:99603-6024
Practice Address - Country:US
Practice Address - Phone:907-299-5669
Practice Address - Fax:907-782-4394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK74176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1599851Medicaid