Healthcare Provider Details

I. General information

NPI: 1760870943
Provider Name (Legal Business Name): JUNE MOON HOME BIRTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 8TH ST
BERKELEY CA
94710-2319
US

IV. Provider business mailing address

2105 8TH ST
BERKELEY CA
94710-2319
US

V. Phone/Fax

Practice location:
  • Phone: 651-239-3895
  • Fax:
Mailing address:
  • Phone: 651-239-3895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number412
License Number StateCA

VIII. Authorized Official

Name: RENEE LEPREAU
Title or Position: MIDWIFE
Credential: LM, CPM
Phone: 651-239-3895