Provider Demographics
NPI:1932622693
Name:FULL MOON FAMILY WELLNESS AND BIRTH CENTER
Entity Type:Organization
Organization Name:FULL MOON FAMILY WELLNESS AND BIRTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:SUNSHINE
Authorized Official - Last Name:TOMLIN
Authorized Official - Suffix:
Authorized Official - Credentials:LM
Authorized Official - Phone:831-454-8031
Mailing Address - Street 1:701 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 MISSION ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3614
Practice Address - Country:US
Practice Address - Phone:831-454-8031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-24
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM192176B00000X
261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
No176B00000XOther Service ProvidersMidwifeGroup - Single Specialty