Provider Demographics
NPI:1578902474
Name:GLOW MIDWIFERY
Entity Type:Organization
Organization Name:GLOW MIDWIFERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:TRUBY
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, LDM
Authorized Official - Phone:971-275-6106
Mailing Address - Street 1:4031 SE SALMON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4434
Mailing Address - Country:US
Mailing Address - Phone:971-275-6106
Mailing Address - Fax:971-200-2669
Practice Address - Street 1:4031 SE SALMON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4434
Practice Address - Country:US
Practice Address - Phone:971-275-6106
Practice Address - Fax:971-200-2669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD-10141148261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500641063Medicaid