Healthcare Provider Details

I. General information

NPI: 1386069326
Provider Name (Legal Business Name): BRIGHT EYES MIDWIFERY AND WILD RIVERS WOMENS HEALTH,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29135 ELLENSBURG AVE
GOLD BEACH OR
97444-8722
US

IV. Provider business mailing address

PO BOX 1710
GOLD BEACH OR
97444-1710
US

V. Phone/Fax

Practice location:
  • Phone: 541-260-5762
  • Fax:
Mailing address:
  • Phone: 541-260-5762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200950160NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number000031286N5
License Number StateOR

VIII. Authorized Official

Name: KATHLEEN WEBER DOUGHERTY
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-260-5762