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General NPI Number Information
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NPI Number | 1477047116
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Entity Type | Organization
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Legal Business Name | ORIGINS BIRTH AND WELLNESS DALLAS
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Dates
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Enumeration Date | 06/17/2018
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Last Update Date | 04/17/2019
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Provider Practice Location Address
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Address Line | 3100 SWISS AVE
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City | DALLAS
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State | TX
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Zip | 75204
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Country | US
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Telephone | 214-228-1392
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Fax |
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Provider Business Mailing Address
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Address Line | 3100 SWISS AVE
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City | DALLAS
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State | TX
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Zip | 75204-6025
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Country | US
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Telephone | 214-228-1392
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Fax |
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Authorized Official
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Title or Position | MIDWIFE
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Name | AMETHYST FAGAN TATE
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Credential | CPM
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Telephone | 214-228-1392
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 176B00000X
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Taxonomy Name | Midwife
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License Number | 99337
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 261QB0400X
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Taxonomy Name | Birthing Clinic/Center
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License Number |
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License Number State |
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