MEDICARE: ORIGINS FUNCTIONAL WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1306326913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORIGINS FUNCTIONAL WELLNESS, LLC

Provider Business Mailing Address
First Line	:	125 PONDEROSA WAY
Second Line	:
City	:	JACKSONVILLE
State	:	OR
Zip	:	97530-9018
Country	:	US
Telephone Number	:	432-638-5747
Fax Number	:

Provider Business Practice Location Address
First Line	:	675 N 5TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	OR
Zip	:	97530-9659
Country	:	US
Telephone Number	:	432-638-5747
Fax Number	:

Authorized Official
Title or Position	:	CONTRACTING
Name	:	KATHLEEN KAY GRIFFIN
Credential	:
Telephone Number	:	541-890-1602

Provider Enumeration Date	:	08/14/2018
Last Update Date	:	08/14/2018

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Directions to “ORIGINS FUNCTIONAL WELLNESS, LLC ” Practice Location

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