Provider Demographics
NPI:1457659906
Name:HEIRLOOM WELLNESS & BIRTH LLC
Entity Type:Organization
Organization Name:HEIRLOOM WELLNESS & BIRTH LLC
Other - Org Name:HERITAGE HEALTH AND BIRTH LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GERRISH
Authorized Official - Suffix:
Authorized Official - Credentials:CDM
Authorized Official - Phone:907-746-6644
Mailing Address - Street 1:2323 S TRUNK RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645
Mailing Address - Country:US
Mailing Address - Phone:907-746-6644
Mailing Address - Fax:317-667-1982
Practice Address - Street 1:2323 S TRUNK RD
Practice Address - Street 2:SUITE 6
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-746-6644
Practice Address - Fax:317-667-1982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
No261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1657481Medicaid
AK1571890Medicaid