Provider Demographics
NPI:1528143435
Name:VIVANTE MIDWIFERY, INC.
Entity type:Organization
Organization Name:VIVANTE MIDWIFERY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, MPH, PMHNP
Authorized Official - Phone:503-652-8076
Mailing Address - Street 1:4110 SE HAWTHORNE BLVD
Mailing Address - Street 2:PMB 267
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5246
Mailing Address - Country:US
Mailing Address - Phone:503-652-8076
Mailing Address - Fax:503-922-0080
Practice Address - Street 1:2625 SE HAWTHORNE BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2941
Practice Address - Country:US
Practice Address - Phone:503-652-8076
Practice Address - Fax:503-922-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR087006548N6163WP0808X
OR087006548N5176B00000X
OR163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR010822Medicaid