Provider Demographics
NPI:1891337895
Name:WILLOW MIDWIFE CENTER FOR BIRTH AND WELLNESS AZ CENTRAL LLC
Entity Type:Organization
Organization Name:WILLOW MIDWIFE CENTER FOR BIRTH AND WELLNESS AZ CENTRAL LLC
Other - Org Name:WILLOW AZ CENTRAL MIDWIVES
Other - Org Type:Other Name
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:480-565-5944
Mailing Address - Street 1:2045 S VINEYARD STE 136
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 E MONTEREY WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2616
Practice Address - Country:US
Practice Address - Phone:480-565-5990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-10
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherN/A