Provider Demographics
NPI:1992123236
Name:ORIGINS BIRTH SERVICES, LLC
Entity type:Organization
Organization Name:ORIGINS BIRTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MIDWIFE
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:RACHEL
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, LM
Authorized Official - Phone:214-680-0956
Mailing Address - Street 1:10340 ALTA VISTA RD STE 1A
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6500
Mailing Address - Country:US
Mailing Address - Phone:817-349-6005
Mailing Address - Fax:817-768-6940
Practice Address - Street 1:10340 ALTA VISTA RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6500
Practice Address - Country:US
Practice Address - Phone:817-349-6005
Practice Address - Fax:817-768-6940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
176B00000X
TX150037261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
No261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthingGroup - Single Specialty