MEDICARE: BIRTHWISE MATERNITY CARE, LC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife	6164811-3400	UT

General Provider Information

NPI Number	:	1336356575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRTHWISE MATERNITY CARE, LC

Provider Business Mailing Address
First Line	:	360 S FORT LN
Second Line	:	SUITE 1B
City	:	LAYTON
State	:	UT
Zip	:	84041-4259
Country	:	US
Telephone Number	:	801-928-9089
Fax Number	:	801-546-3207

Provider Business Practice Location Address
First Line	:	360 S FORT LN
Second Line	:	SUITE 1B
City	:	LAYTON
State	:	UT
Zip	:	84041-4259
Country	:	US
Telephone Number	:	801-928-9089
Fax Number	:	801-546-3207

Authorized Official
Title or Position	:	MEMBER
Name	:	JANELL PETERSON
Credential	:	LDEM, CPM
Telephone Number	:	801-928-9089

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	02/14/2014

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