Provider Demographics
NPI:1104700897
Name:ORIGIN HEALTH LLC
Entity type:Organization
Organization Name:ORIGIN HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MERLIN
Authorized Official - Middle Name:BARDETT
Authorized Official - Last Name:FAUSETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-523-5650
Mailing Address - Street 1:2831 FORT MISSOULA RD STE 232
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7479
Mailing Address - Country:US
Mailing Address - Phone:406-523-5650
Mailing Address - Fax:855-823-5532
Practice Address - Street 1:2831 FORT MISSOUA ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804
Practice Address - Country:US
Practice Address - Phone:406-523-5650
Practice Address - Fax:855-823-5532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORIGIN HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing