Provider Demographics
NPI:1659542579
Name:MOUNTAIN MIDWIFERY CENTER INC
Entity Type:Organization
Organization Name:MOUNTAIN MIDWIFERY CENTER INC
Other - Org Name:MOUNTAIN MIDWIFERY GROUP MIDWIVES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:303-788-0600
Mailing Address - Street 1:3535 S LAFAYETTE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3957
Mailing Address - Country:US
Mailing Address - Phone:303-788-0600
Mailing Address - Fax:303-788-0602
Practice Address - Street 1:3535 S LAFAYETTE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3957
Practice Address - Country:US
Practice Address - Phone:303-788-0600
Practice Address - Fax:303-788-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40G369261QB0400X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthingGroup - Single Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO63674351Medicaid