45D2091330 CLIA NUMBER - ORIGINS BIRTH AND WELLNESS COLLECTIVE

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Laboratory Demographics

CLIA Number: 45D2091330

Facility Name: ORIGINS BIRTH AND WELLNESS COLLECTIVE

Facility Address:
10340 ALTA VISTA ROAD
FORT WORTH, TX
ZIP 76244
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Facility Phone Number: 817 562-2828

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1003211756

Taxonomy: 175M00000X - Midwife, Lay
A person qualified by experience and limited specialized training to provide obstetric and neo-natal care in the management of women having normal pregnancy, labor and childbirth. The lay midwife is licensed in some states.

CLIA Record

Field Name	Field Value
CLIA Number	45D2091330
LAB Type	Practitioner Other
Facility Name	ORIGINS BIRTH AND WELLNESS COLLECTIVE
Street	10340 ALTA VISTA ROAD
City	FORT WORTH
State	TX
ZIP	76244
Phone	817 562-2828
CertificateType	4
CertificateEffectiveDate	2/11/2023
CertificateExpirationDate	2/10/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024