Healthcare Provider Details

I. General information

NPI: 1205752995
Provider Name (Legal Business Name): ORIGIN MIDWIVES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 HEATHROW AVE
CASPER WY
82609-3933
US

IV. Provider business mailing address

2165 HEATHROW AVE
CASPER WY
82609-3933
US

V. Phone/Fax

Practice location:
  • Phone: 307-439-6390
  • Fax: 520-380-4886
Mailing address:
  • Phone: 307-439-6390
  • Fax: 520-380-4886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KIM PEKIN
Title or Position: MANAGING MEMBER
Credential: CNM
Phone: 240-422-3889