Healthcare Provider Details

I. General information

NPI: 1235509183
Provider Name (Legal Business Name): LITTLE STAR BIRTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10305 YORKTOWN CT
GREAT FALLS VA
22066-4217
US

IV. Provider business mailing address

21010 SOUTHBANK ST # 2050
STERLING VA
20165-7227
US

V. Phone/Fax

Practice location:
  • Phone: 571-438-3224
  • Fax:
Mailing address:
  • Phone: 571-438-3224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number0129000102
License Number StateVA

VIII. Authorized Official

Name: REBECCA R BANKS
Title or Position: OWNER
Credential: CPM, LM
Phone: 571-438-3224