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General NPI Number Information
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NPI Number | 1851086607
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Entity Type | Organization
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Legal Business Name | ORIGINS WELLNESS PLLC
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Dates
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Enumeration Date | 04/07/2023
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 10345 ALTA VISTA RD
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City | FORT WORTH
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State | TX
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Zip | 76244-6501
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Country | US
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Telephone | 817-562-2828
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Fax | 817-768-6940
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Provider Business Mailing Address
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Address Line | 10345 ALTA VISTA RD
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City | FORT WORTH
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State | TX
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Zip | 76244-6501
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Country | US
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Telephone | 817-562-2828
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Fax | 817-768-6940
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Authorized Official
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Title or Position | FINANCIAL DIRECTOR
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Name | AME COCHENOUR
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Credential |
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Telephone | 817-697-4345
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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