Provider Demographics
NPI:1285990267
Name:WISE WOMEN CARE ASSOCIATES
Entity type:Organization
Organization Name:WISE WOMEN CARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR/MIDWIFE
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, LDM
Authorized Official - Phone:541-772-2291
Mailing Address - Street 1:400 CRATER LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6808
Mailing Address - Country:US
Mailing Address - Phone:541-772-2291
Mailing Address - Fax:541-245-0417
Practice Address - Street 1:400 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6808
Practice Address - Country:US
Practice Address - Phone:541-772-2291
Practice Address - Fax:541-245-0417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDM10119128176B00000X
OR200750100NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty