Provider Demographics
NPI:1962835306
Name:ORIGINS FAMILY MEDICAL & WEIGHT LOSS CLINIC INC
Entity Type:Organization
Organization Name:ORIGINS FAMILY MEDICAL & WEIGHT LOSS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:386-755-5014
Mailing Address - Street 1:194 SW WALL TER
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5086
Mailing Address - Country:US
Mailing Address - Phone:386-719-9227
Mailing Address - Fax:386-719-9488
Practice Address - Street 1:206 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-7058
Practice Address - Country:US
Practice Address - Phone:386-755-5014
Practice Address - Fax:386-755-3093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty