| Organization Name: | ORIGIN PREGNANCY BOUTIQUE |
| NPI Number: | 1255661583 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | AMY DAVIS (OWNER/SONOGRAPHER) |
| Mailing Address: | 45040 Main Street B Mendocino |
| State: | CA US |
| Postal Code: | 95460 |
| Phone Number: | 7079371477 |
| Fax Number: | 7079371480 |
| NPI Enumeration Date: | 01/08/2010 |
| NPI Last Update Date: | 01/08/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2471S1302X |
| License Number: | RDMS81478 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Technologists, Technicians & Other Technical Service Providers |
| Taxonomy Classification: | Radiologic Technologist |
| Taxonomy Specialization: | Sonography |
| Taxonomy Definition: | |