Basic Information
| Provider Information | |||||||||
| NPI: | 1720459894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLOOMIN' BABIES BIRTH CENTER, LLC | ||||||||
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| OtherOrganizationName: | BLOOMIN' BABIES GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2241 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815017423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705894143 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2241 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815017423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705491711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2015 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KANDIKO | ||||||||
| AuthorizedOfficialFirstName: | PATTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CNM | ||||||||
| AuthorizedOfficialTelephone: | 9702794545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 163WL0100X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Lactation Consultant | 176B00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 367A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 62975862 | 05 | CO | MEDICAID |