Healthcare Provider Details

I. General information

NPI: 1982058491
Provider Name (Legal Business Name): ROGUE BIRTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 REDWOOD CIR
GRANTS PASS OR
97527-5523
US

IV. Provider business mailing address

1453 REDWOOD CIR
GRANTS PASS OR
97527-5523
US

V. Phone/Fax

Practice location:
  • Phone: 541-210-0134
  • Fax:
Mailing address:
  • Phone: 541-210-0134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: WILLA ANNE WOODARD ERVIN
Title or Position: OWNER & DIRECTOR
Credential: CPM, LDM
Phone: 541-210-0134