1780300806 NPI number — MOTHERROOT INTEGRATED WELLNESS

Table of content: (NPI 1780300806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780300806 NPI number — MOTHERROOT INTEGRATED WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOTHERROOT INTEGRATED WELLNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780300806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 HOLLY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97520-2926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-325-1550
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 CLEAR CREEK DR UNIT 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97520-1882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-414-3808
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC MANAGER/ PA
Authorized Official Telephone Number:
541-414-3808

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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