Provider Demographics
NPI:1477047116
Name:ORIGINS BIRTH AND WELLNESS DALLAS
Entity type:Organization
Organization Name:ORIGINS BIRTH AND WELLNESS DALLAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MIDWIFE
Authorized Official - Prefix:
Authorized Official - First Name:AMETHYST
Authorized Official - Middle Name:FAGAN
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:CPM
Authorized Official - Phone:214-228-1392
Mailing Address - Street 1:3100 SWISS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-6025
Mailing Address - Country:US
Mailing Address - Phone:214-228-1392
Mailing Address - Fax:
Practice Address - Street 1:3100 SWISS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204
Practice Address - Country:US
Practice Address - Phone:214-228-1392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99337176B00000X
261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
No176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147744198Medicaid