Healthcare Provider Details

I. General information

NPI: 1043897986
Provider Name (Legal Business Name): MAMA NATURAL BIRTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 OKEECHOBEE CIR
SANTA ROSA BEACH FL
32459-8798
US

IV. Provider business mailing address

86 OKEECHOBEE CIR
SANTA ROSA BEACH FL
32459-8798
US

V. Phone/Fax

Practice location:
  • Phone: 312-259-4587
  • Fax:
Mailing address:
  • Phone: 312-259-4587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL HOWLAND PUGH
Title or Position: PARTNER
Credential:
Phone: 312-259-4587