=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881272821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OREGON BIRTH AND WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2021
-----------------------------------------------------
Last Update Date | 03/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 890 BELTLINE RD
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97477-1091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-515-6556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 67TH ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97478-7184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CNM, BOARD PRESIDENT
-----------------------------------------------------
Name | KELLY RICKMAN
-----------------------------------------------------
Credential | CNM, DNP
-----------------------------------------------------
Telephone | 541-654-9076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QB0400X
-----------------------------------------------------
Taxonomy Name | Birthing Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------