Provider Demographics
NPI:1255661583
Name:ORIGIN PREGNANCY BOUTIQUE
Entity Type:Organization
Organization Name:ORIGIN PREGNANCY BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SONOGRAPHER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:707-937-1477
Mailing Address - Street 1:33275 PACIFIC WAY
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-9226
Mailing Address - Country:US
Mailing Address - Phone:707-937-1477
Mailing Address - Fax:707-937-1480
Practice Address - Street 1:45040 MAIN STREET
Practice Address - Street 2:B
Practice Address - City:MENDOCINO
Practice Address - State:CA
Practice Address - Zip Code:95460
Practice Address - Country:US
Practice Address - Phone:707-937-1477
Practice Address - Fax:707-937-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDMS814782471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty