Healthcare Provider Details

I. General information

NPI: 1194226654
Provider Name (Legal Business Name): HERITAGE BIRTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 KNOXVILLE AVE
LUBBOCK TX
79413
US

IV. Provider business mailing address

3410 KNOXVILLE AVE
LUBBOCK TX
79413
US

V. Phone/Fax

Practice location:
  • Phone: 806-224-8617
  • Fax: 806-329-2632
Mailing address:
  • Phone: 806-224-8617
  • Fax: 806-329-2632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number150068
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number99178
License Number StateTX

VIII. Authorized Official

Name: ALEXANDRA WYATT
Title or Position: OWNER
Credential: LM, CPM
Phone: 818-421-1355