Healthcare Provider Details

I. General information

NPI: 1003583683
Provider Name (Legal Business Name): ORIGIN HEALTHCARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001A E HARMONY RD STE 308
FORT COLLINS CO
80525-3354
US

IV. Provider business mailing address

1001A E HARMONY RD STE 308
FORT COLLINS CO
80525-3354
US

V. Phone/Fax

Practice location:
  • Phone: 904-746-4640
  • Fax:
Mailing address:
  • Phone: 904-746-4640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE M. LUM LUNG
Title or Position: OWNER
Credential:
Phone: 888-777-2718