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General NPI Number Information
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NPI Number | 1255661583
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Entity Type | Organization
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Legal Business Name | ORIGIN PREGNANCY BOUTIQUE
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Dates
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Enumeration Date | 01/08/2010
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Last Update Date | 01/08/2010
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Provider Practice Location Address
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Address Line | 45040 MAIN STREET B
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City | MENDOCINO
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State | CA
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Zip | 95460
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Country | US
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Telephone | 707-937-1477
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Fax | 707-937-1480
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Provider Business Mailing Address
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Address Line | 33275 PACIFIC WAY
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City | FORT BRAGG
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State | CA
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Zip | 95437-9226
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Country | US
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Telephone | 707-937-1477
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Fax | 707-937-1480
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Authorized Official
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Title or Position | OWNER/SONOGRAPHER
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Name | AMY DAVIS
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Credential | RDMS
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Telephone | 707-937-1477
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2471S1302X
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Taxonomy Name | Sonography Radiologic Technologist
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License Number | RDMS81478
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License Number State | CA
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