=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174929921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY GENTLE BIRTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2014
-----------------------------------------------------
Last Update Date | 11/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 GOLD KETTLE DR
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20878-2721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-631-8177
-----------------------------------------------------
Fax | 801-659-8177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 GOLD KETTLE DR
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20878-2721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-631-8177
-----------------------------------------------------
Fax | 801-659-8177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOULA
-----------------------------------------------------
Name | MRS. ROSE MARIAN QUINTILIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-631-8177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374J00000X
-----------------------------------------------------
Taxonomy Name | Doula
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------