Provider Demographics
NPI:1790351088
Name:ORIGIN PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ORIGIN PHYSICAL THERAPY
Other - Org Name:ORIGIN PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:TABOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:702-623-8555
Mailing Address - Street 1:6480 S TENAYA WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-6655
Mailing Address - Country:US
Mailing Address - Phone:702-623-8555
Mailing Address - Fax:702-623-8545
Practice Address - Street 1:6480 S TENAYA WAY STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-6655
Practice Address - Country:US
Practice Address - Phone:702-623-8555
Practice Address - Fax:702-623-8545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-27
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy