Provider Demographics
NPI:1386069326
Name:BRIGHT EYES MIDWIFERY AND WILD RIVERS WOMENS HEALTH,LLC
Entity type:Organization
Organization Name:BRIGHT EYES MIDWIFERY AND WILD RIVERS WOMENS HEALTH,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:WEBER
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-260-5762
Mailing Address - Street 1:PO BOX 1710
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-1710
Mailing Address - Country:US
Mailing Address - Phone:541-260-5762
Mailing Address - Fax:
Practice Address - Street 1:29135 ELLENSBURG AVE
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-8722
Practice Address - Country:US
Practice Address - Phone:541-260-5762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200950160NP363L00000X
OR000031286N5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR172189Medicaid
OR500614877Medicaid