Provider Demographics
NPI:1700441672
Name:BEAUTIFUL MOUNTAIN BIRTH & MIDWIFERY
Entity Type:Organization
Organization Name:BEAUTIFUL MOUNTAIN BIRTH & MIDWIFERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:BLACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, LDEM
Authorized Official - Phone:801-200-1873
Mailing Address - Street 1:826 E 12300 S STE 2
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8276
Mailing Address - Country:US
Mailing Address - Phone:801-252-6243
Mailing Address - Fax:801-901-4531
Practice Address - Street 1:7611 S JORDAN LANDING BLVD STE 120&130
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-5610
Practice Address - Country:US
Practice Address - Phone:801-252-6243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAUTIFUL MOUNTAIN BIRTH SUITES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty