Healthcare Provider Details

I. General information

NPI: 1578902474
Provider Name (Legal Business Name): GLOW MIDWIFERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4031 SE SALMON ST
PORTLAND OR
97214-4434
US

IV. Provider business mailing address

4031 SE SALMON ST
PORTLAND OR
97214-4434
US

V. Phone/Fax

Practice location:
  • Phone: 971-275-6106
  • Fax: 971-200-2669
Mailing address:
  • Phone: 971-275-6106
  • Fax: 971-200-2669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License NumberDEM-LD-10141148
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500641063
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MS. ANGELA CHRISTINE TRUBY
Title or Position: PROPRIETOR
Credential: CPM, LDM
Phone: 971-275-6106