MEDICARE: NICOLE ALYCE BENDOTOFF CPM, LDM

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	DEM-LD-10160044	OR

General Provider Information

NPI Number	:	1790116291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ALYCE BENDOTOFF CPM, LDM

Provider Business Mailing Address
First Line	:	4228 SE 74TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-3416
Country	:	US
Telephone Number	:	503-294-3896
Fax Number	:	888-972-7341

Provider Business Practice Location Address
First Line	:	4228 SE 74TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-3416
Country	:	US
Telephone Number	:	503-294-3896
Fax Number	:	888-972-7341

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2013
Last Update Date	:	12/09/2013

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