Provider Demographics
NPI:1164882437
Name:ORIGINS FUNCTIONAL MEDICINE, LLC
Entity Type:Organization
Organization Name:ORIGINS FUNCTIONAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTEOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-902-4912
Mailing Address - Street 1:260 LOOKOUT PL STE 106
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4485
Mailing Address - Country:US
Mailing Address - Phone:407-902-1942
Mailing Address - Fax:
Practice Address - Street 1:260 LOOKOUT PL STE 106
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4485
Practice Address - Country:US
Practice Address - Phone:407-902-1942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty