Healthcare Provider Details

I. General information

NPI: 1790865855
Provider Name (Legal Business Name): COLUMBIA GORGE MIDWIFERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 FREEDOM DR
HOOD RIVER OR
97031-8671
US

IV. Provider business mailing address

2324 FREEDOM DR
HOOD RIVER OR
97031-8671
US

V. Phone/Fax

Practice location:
  • Phone: 541-490-3140
  • Fax: 541-386-8365
Mailing address:
  • Phone: 541-490-3140
  • Fax: 541-386-8365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number10113722
License Number StateOR

VIII. Authorized Official

Name: MRS. LYNETTE TILLEY
Title or Position: OWNER
Credential: CPM,LDM
Phone: 541-490-3140