Provider Demographics
NPI:1457812810
Name:BIRTH WAVES MIDWIFERY
Entity Type:Organization
Organization Name:BIRTH WAVES MIDWIFERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LM, CPM
Authorized Official - Phone:858-221-6040
Mailing Address - Street 1:3830 VALLEY CENTRE DR # 705-246
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3320
Mailing Address - Country:US
Mailing Address - Phone:858-221-6040
Mailing Address - Fax:
Practice Address - Street 1:3830 VALLEY CENTRE DR # 705-246
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3320
Practice Address - Country:US
Practice Address - Phone:858-221-6040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty