Healthcare Provider Details

I. General information

NPI: 1770895187
Provider Name (Legal Business Name): BACK COVE MIDWIVES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 OCEAN AVE
PORTLAND ME
04103-4972
US

IV. Provider business mailing address

527 OCEAN AVE
PORTLAND ME
04103-4972
US

V. Phone/Fax

Practice location:
  • Phone: 207-871-0666
  • Fax:
Mailing address:
  • Phone: 207-871-0666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number StateME

VIII. Authorized Official

Name: EILEEN GRILLO
Title or Position: OWNER
Credential: CNM
Phone: 207-871-0666