Healthcare Provider Details

I. General information

NPI: 1164221347
Provider Name (Legal Business Name): ITHIOPIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2025
Last Update Date: 03/11/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10485 FOLSOM BVLD SUITE B
RANCHO CORDOVA CA
95670
US

IV. Provider business mailing address

10436 COLOMA RD # 22
RANCHO CORDOVA CA
95670-2157
US

V. Phone/Fax

Practice location:
  • Phone: 279-465-1236
  • Fax:
Mailing address:
  • Phone: 279-465-1236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: ITHOPIA MCKINNEY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 279-465-1236