Provider Demographics
NPI:1003211756
Name:ORIGINS BIRTH SERVICES, LLC
Entity Type:Organization
Organization Name:ORIGINS BIRTH SERVICES, LLC
Other - Org Name:ORIGINS BIRTH AND WELLNESS COLLECTIVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MIDWIFE/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAITLYN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:WAGES
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, LM
Authorized Official - Phone:817-966-8075
Mailing Address - Street 1:10340 ALTA VISTA RD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6500
Mailing Address - Country:US
Mailing Address - Phone:817-562-2828
Mailing Address - Fax:817-768-6940
Practice Address - Street 1:10340 ALTA VISTA RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6500
Practice Address - Country:US
Practice Address - Phone:817-562-2828
Practice Address - Fax:817-768-6940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99220175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175M00000XOther Service ProvidersMidwife, LayGroup - Single Specialty