Healthcare Provider Details

I. General information

NPI: 1851086607
Provider Name (Legal Business Name): ORIGINS WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10345 ALTA VISTA RD
FORT WORTH TX
76244-6501
US

IV. Provider business mailing address

10345 ALTA VISTA RD
FORT WORTH TX
76244-6501
US

V. Phone/Fax

Practice location:
  • Phone: 817-562-2828
  • Fax: 817-768-6940
Mailing address:
  • Phone: 817-562-2828
  • Fax: 817-768-6940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AME COCHENOUR
Title or Position: FINANCIAL DIRECTOR
Credential:
Phone: 817-697-4345