Provider Demographics
NPI:1679350698
Name:CREEKSIDE BIRTH COTTAGE
Entity Type:Organization
Organization Name:CREEKSIDE BIRTH COTTAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-951-6410
Mailing Address - Street 1:215 W FRONTIER ST
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 W FRONTIER ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5318
Practice Address - Country:US
Practice Address - Phone:928-951-6410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CREEKSIDE MIDWIFERY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty