Provider Demographics
NPI:1184906299
Name:ORIGIN CHIROPRACTIC PHYSICIANS, PC
Entity type:Organization
Organization Name:ORIGIN CHIROPRACTIC PHYSICIANS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOK
Authorized Official - Middle Name:A
Authorized Official - Last Name:TOWNLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-280-2599
Mailing Address - Street 1:1203 28TH ST S STE A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8711
Mailing Address - Country:US
Mailing Address - Phone:701-280-2599
Mailing Address - Fax:701-280-2915
Practice Address - Street 1:1203 28TH ST S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8711
Practice Address - Country:US
Practice Address - Phone:701-280-2599
Practice Address - Fax:701-280-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND635111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN09D810ROtherBCBS MN
ND350051247OtherRR MEDICARE
ND17927OtherBCBS ND
ND350051247OtherRR MEDICARE
NDU65559Medicare UPIN