Healthcare Provider Details

I. General information

NPI: 1619896594
Provider Name (Legal Business Name): ORIGIN RESTORE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 E 18TH ST STE 102
SIOUX FALLS SD
57110-2711
US

IV. Provider business mailing address

704 S 4TH CIR
BRANDON SD
57005-1203
US

V. Phone/Fax

Practice location:
  • Phone: 507-227-7573
  • Fax:
Mailing address:
  • Phone: 507-227-7573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: HANNAH MULARONI
Title or Position: OWNER
Credential:
Phone: 507-227-7573