Provider Demographics
NPI:1477283042
Name:ORIGIN FAMILY WELLNESS LLC
Entity Type:Organization
Organization Name:ORIGIN FAMILY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KISLUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-774-9004
Mailing Address - Street 1:1811 BETHLEHEM PIKE STE A101
Mailing Address - Street 2:
Mailing Address - City:FLOURTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19031-1111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1811 BETHLEHEM PIKE STE A101
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-1111
Practice Address - Country:US
Practice Address - Phone:215-774-9004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-15
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care