Provider Demographics
NPI:1740476332
Name:TREE OF LIFE MIDWIFERY
Entity type:Organization
Organization Name:TREE OF LIFE MIDWIFERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:315-386-4458
Mailing Address - Street 1:89 RIVERSIDE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3398
Mailing Address - Country:US
Mailing Address - Phone:315-386-4458
Mailing Address - Fax:315-379-1275
Practice Address - Street 1:89 RIVERSIDE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3398
Practice Address - Country:US
Practice Address - Phone:315-386-4458
Practice Address - Fax:315-379-1275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000954367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02147175Medicaid
NY02147175Medicaid