Provider Demographics
NPI:1700433174
Name:ORIGIN HEALTH - CHIROPRACTIC & WELLNESS, PROF. LLC
Entity Type:Organization
Organization Name:ORIGIN HEALTH - CHIROPRACTIC & WELLNESS, PROF. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:307-286-2994
Mailing Address - Street 1:5413 S BREEZEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8628
Mailing Address - Country:US
Mailing Address - Phone:307-286-2994
Mailing Address - Fax:
Practice Address - Street 1:5800 E 18TH ST STE 102
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-2711
Practice Address - Country:US
Practice Address - Phone:307-286-2994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty