1669063368 NPI number — MENDING ROOTS NATUROPATHY LLC

Table of content: MS. KATRINA ANNE MCMAHAN R.D.H. (NPI 1538175518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669063368 NPI number — MENDING ROOTS NATUROPATHY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENDING ROOTS NATUROPATHY LLC
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:
1669063368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 RIMMONDALE ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEYMOUR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06483-2931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 RIVER ST UNIT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06460-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-442-6297
Provider Business Practice Location Address Fax Number:
833-520-5011
Provider Enumeration Date:
01/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WOOMER
Authorized Official First Name:
SUZANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
203-442-6297

Provider Taxonomy Codes

  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1790226421 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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