MEDICARE: ORIGIN HOSPITALITY 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	310400000X	Assisted Living Facility	AL11478	FL

General Provider Information

NPI Number	:	1841532025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORIGIN HOSPITALITY LLC

Provider Business Mailing Address
First Line	:	17503 LA CANTERA PKWY #104618
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257
Country	:	US
Telephone Number	:	832-385-2295
Fax Number	:	855-557-2835

Provider Business Practice Location Address
First Line	:	2910 OLD CANOE CREEK RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772
Country	:	US
Telephone Number	:	407-593-1524
Fax Number	:	407-593-1525

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. MITESH PATEL
Credential	:
Telephone Number	:	832-385-2295

Provider Enumeration Date	:	03/26/2013
Last Update Date	:	09/25/2019

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