Healthcare Provider Details

I. General information

NPI: 1477047116
Provider Name (Legal Business Name): ORIGINS BIRTH AND WELLNESS DALLAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2018
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SWISS AVE
DALLAS TX
75204
US

IV. Provider business mailing address

3100 SWISS AVE
DALLAS TX
75204-6025
US

V. Phone/Fax

Practice location:
  • Phone: 214-228-1392
  • Fax:
Mailing address:
  • Phone: 214-228-1392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number99337
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMETHYST FAGAN TATE
Title or Position: MIDWIFE
Credential: CPM
Phone: 214-228-1392