Provider Demographics
NPI:1093326969
Name:ORIGIN SPINE INSTITUTE LLC
Entity Type:Organization
Organization Name:ORIGIN SPINE INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-856-2988
Mailing Address - Street 1:9135 KATY FWY STE 300
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-1619
Mailing Address - Country:US
Mailing Address - Phone:832-655-4846
Mailing Address - Fax:
Practice Address - Street 1:9135 KATY FWY STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1619
Practice Address - Country:US
Practice Address - Phone:832-856-2988
Practice Address - Fax:888-597-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty