Healthcare Provider Details

I. General information

NPI: 1770905937
Provider Name (Legal Business Name): BABY ROOTS BIRTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S PALMETTO AVE SUITE 158
DAYTONA BEACH FL
32114-4387
US

IV. Provider business mailing address

119 S PALMETTO AVE SUITE 158
DAYTONA BEACH FL
32114-4387
US

V. Phone/Fax

Practice location:
  • Phone: 386-562-8213
  • Fax:
Mailing address:
  • Phone: 386-562-8213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberBT-72927
License Number StateFL

VIII. Authorized Official

Name: MRS. JESSE MARIE ALBATROSOV
Title or Position: OWNER
Credential: CLC, CCE
Phone: 386-562-8213