Healthcare Provider Details

I. General information

NPI: 1285990267
Provider Name (Legal Business Name): WISE WOMEN CARE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CRATER LAKE AVE
MEDFORD OR
97504-6808
US

IV. Provider business mailing address

400 CRATER LAKE AVE
MEDFORD OR
97504-6808
US

V. Phone/Fax

Practice location:
  • Phone: 541-772-2291
  • Fax: 541-245-0417
Mailing address:
  • Phone: 541-772-2291
  • Fax: 541-245-0417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLDM10119128
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200750100NP
License Number StateOR

VIII. Authorized Official

Name: AUGUSTINE COLEBROOK
Title or Position: OWNER/DIRECTOR/MIDWIFE
Credential: CPM, LDM
Phone: 541-772-2291