Provider Demographics
NPI:1457596769
Name:MAGIC VALLEY MIDWIFERY, LLC
Entity type:Organization
Organization Name:MAGIC VALLEY MIDWIFERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSE-MIDWIFE
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WOLCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:208-324-2778
Mailing Address - Street 1:276 S 360 W
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-6037
Mailing Address - Country:US
Mailing Address - Phone:208-324-2778
Mailing Address - Fax:208-324-2778
Practice Address - Street 1:102 E AVENUE F
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-3133
Practice Address - Country:US
Practice Address - Phone:208-324-2778
Practice Address - Fax:208-324-2778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNM-24A261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility