Provider Demographics
NPI:1295023893
Name:THIRTEENTH MOON MIDWIFERY
Entity Type:Organization
Organization Name:THIRTEENTH MOON MIDWIFERY
Other - Org Name:13TH MOON MIDWIFERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CNM/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROEDOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-221-3496
Mailing Address - Street 1:912 WILD CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-1365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:912 WILD CHERRY LN
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-1365
Practice Address - Country:US
Practice Address - Phone:970-221-3496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-16
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN118053261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10788263Medicaid