Healthcare Provider Details

I. General information

NPI: 1174453757
Provider Name (Legal Business Name): ORIGIN HEALTH & LONGEVITY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2026
Last Update Date: 05/23/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4686 N ALAMEDA CREEK AVE
MERIDIAN ID
83646-2017
US

IV. Provider business mailing address

4686 N ALAMEDA CREEK AVE
MERIDIAN ID
83646-2017
US

V. Phone/Fax

Practice location:
  • Phone: 208-283-4929
  • Fax:
Mailing address:
  • Phone: 208-283-4929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL KENT BUTTARS
Title or Position: OWNER
Credential: NP
Phone: 208-283-4929