Provider Demographics
NPI:1639881295
Name:WILD AT HEART BIRTH CENTER
Entity Type:Organization
Organization Name:WILD AT HEART BIRTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MIDWIFE / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LM
Authorized Official - Phone:951-553-9804
Mailing Address - Street 1:40700 CALIFORNIA OAKS RD STE 108
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5789
Mailing Address - Country:US
Mailing Address - Phone:951-553-9804
Mailing Address - Fax:951-602-8181
Practice Address - Street 1:40700 CALIFORNIA OAKS RD STE 108
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5789
Practice Address - Country:US
Practice Address - Phone:951-553-9804
Practice Address - Fax:951-602-8181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
No176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
No251E00000XAgenciesHome Health
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7053443Medicaid