1205182961 NPI number — HOME4BIRTH LLC

Table of content: (NPI 1205182961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205182961 NPI number — HOME4BIRTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOME4BIRTH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HOME4BIRTH
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205182961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12840 FORD DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FISHERS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46038-2894
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-643-9433
Provider Business Mailing Address Fax Number:
765-250-9389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12987 PARKSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FISHERS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46038-3864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-643-9433
Provider Business Practice Location Address Fax Number:
317-355-6029
Provider Enumeration Date:
07/31/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRAHAM-WOOD
Authorized Official First Name:
BRANDI
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
MIDWIFE
Authorized Official Telephone Number:
765-643-9433

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  72000118A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)