Healthcare Provider Details

I. General information

NPI: 1467701805
Provider Name (Legal Business Name): BIRTH AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 W TERRA LN
O FALLON MO
63366-2432
US

IV. Provider business mailing address

27880 BEVERLY DR
WRIGHT CITY MO
63390-4449
US

V. Phone/Fax

Practice location:
  • Phone: 314-369-8637
  • Fax: 877-533-4456
Mailing address:
  • Phone: 314-369-8637
  • Fax: 877-533-4456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number2010015977
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number100863
License Number StateMO

VIII. Authorized Official

Name: JESSICA HENMAN
Title or Position: DIRECTOR
Credential: CNM
Phone: 314-369-8637