Provider Demographics
NPI:1528462090
Name:MOUNTAINLAND FAMILY AND BIRTH CENTER
Entity type:Organization
Organization Name:MOUNTAINLAND FAMILY AND BIRTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MIDWIFE
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:BLACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, LDEM
Authorized Official - Phone:801-200-1873
Mailing Address - Street 1:1416 N REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-6455
Mailing Address - Country:US
Mailing Address - Phone:801-252-6243
Mailing Address - Fax:801-407-1821
Practice Address - Street 1:36 SUMMER PL
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-6408
Practice Address - Country:US
Practice Address - Phone:801-200-1873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2864863400176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty