Provider Demographics
NPI:1841532025
Name:ORIGIN HOSPITALITY LLC
Entity type:Organization
Organization Name:ORIGIN HOSPITALITY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MITESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-385-2295
Mailing Address - Street 1:17503 LA CANTERA PKWY #104618
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257
Mailing Address - Country:US
Mailing Address - Phone:832-385-2295
Mailing Address - Fax:855-557-2835
Practice Address - Street 1:2910 OLD CANOE CREEK RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772
Practice Address - Country:US
Practice Address - Phone:407-593-1524
Practice Address - Fax:407-593-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11478310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility