Provider Demographics
NPI:1902217557
Name:ORIGINS NATURAL MEDICINE
Entity Type:Organization
Organization Name:ORIGINS NATURAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:360-385-5375
Mailing Address - Street 1:213 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-4623
Mailing Address - Country:US
Mailing Address - Phone:360-385-5375
Mailing Address - Fax:360-343-0101
Practice Address - Street 1:213 DECATUR ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-4623
Practice Address - Country:US
Practice Address - Phone:360-385-5375
Practice Address - Fax:360-343-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60241039305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization