Healthcare Provider Details

I. General information

NPI: 1508296971
Provider Name (Legal Business Name): KALISTA BIRTH SANCTUARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 E JACKSON ST
MEDFORD OR
97504
US

IV. Provider business mailing address

924 E JACKSON ST
MEDFORD OR
97504
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-0100
  • Fax: 541-779-0107
Mailing address:
  • Phone: 541-779-0100
  • Fax: 541-779-0107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number83-OB
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1556
License Number StateOR

VIII. Authorized Official

Name: DR. WENDY HALE
Title or Position: NATUROPATHIC DOCTOR
Credential: ND
Phone: 541-779-0100