Provider Demographics
NPI:1508296971
Name:KALISTA BIRTH SANCTUARY LLC
Entity Type:Organization
Organization Name:KALISTA BIRTH SANCTUARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATUROPATHIC DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:541-779-0100
Mailing Address - Street 1:924 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-779-0100
Mailing Address - Fax:541-779-0107
Practice Address - Street 1:924 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-779-0100
Practice Address - Fax:541-779-0107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1556175F00000X
OR83-OB176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty