MEDICARE: FULL BLOOM MIDWIFERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0050X	Non-Surgical Family Planning Clinic/Center	1784	CA

General Provider Information

NPI Number	:	1457667180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL BLOOM MIDWIFERY

Provider Business Mailing Address
First Line	:	722 N MAIN ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-3017
Country	:	US
Telephone Number	:	707-964-8808
Fax Number	:	707-964-8808

Provider Business Practice Location Address
First Line	:	722 N MAIN ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-3017
Country	:	US
Telephone Number	:	707-964-8808
Fax Number	:	707-964-8808

Authorized Official
Title or Position	:	PARTNER
Name	:	MS. JENNA BRETON
Credential	:	MSN, CNM
Telephone Number	:	707-964-8808

Provider Enumeration Date	:	08/18/2010
Last Update Date	:	08/18/2010

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