Provider Demographics
NPI:1447374400
Name:COASTAL FAMILY BIRTH RETREAT, LLC
Entity type:Organization
Organization Name:COASTAL FAMILY BIRTH RETREAT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CPM, NHCM
Authorized Official - Phone:603-580-2327
Mailing Address - Street 1:13 FRYING PAN LN
Mailing Address - Street 2:
Mailing Address - City:STRATHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03885-2506
Mailing Address - Country:US
Mailing Address - Phone:603-580-2327
Mailing Address - Fax:603-580-2326
Practice Address - Street 1:13 FRYING PAN LN
Practice Address - Street 2:
Practice Address - City:STRATHAM
Practice Address - State:NH
Practice Address - Zip Code:03885-2506
Practice Address - Country:US
Practice Address - Phone:603-580-2327
Practice Address - Fax:603-580-2326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1009175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175M00000XOther Service ProvidersMidwife, LayGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30462658Medicaid
NH30464876Medicaid