1255661583 NPI number — ORIGIN PREGNANCY BOUTIQUE

Table of content: (NPI 1255661583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255661583 NPI number — ORIGIN PREGNANCY BOUTIQUE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORIGIN PREGNANCY BOUTIQUE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255661583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33275 PACIFIC WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95437-9226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-937-1477
Provider Business Mailing Address Fax Number:
707-937-1480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45040 MAIN STREET
Provider Second Line Business Practice Location Address:
B
Provider Business Practice Location Address City Name:
MENDOCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-937-1477
Provider Business Practice Location Address Fax Number:
707-937-1480
Provider Enumeration Date:
01/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/SONOGRAPHER
Authorized Official Telephone Number:
707-937-1477

Provider Taxonomy Codes

  • Taxonomy code: 2471S1302X , with the licence number:  RDMS81478 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com