MEDICARE: ROOTS4CHANGE COOP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1730915190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOTS4CHANGE COOP

Provider Business Mailing Address
First Line	:	701 E WASHINGTON AVE STE 102
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53703-2958
Country	:	US
Telephone Number	:	904-385-8151
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 E WASHINGTON AVE STE 102
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53703-2958
Country	:	US
Telephone Number	:	904-385-8151
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JENNIFER VALENCIA
Credential	:
Telephone Number	:	704-884-5284

Provider Enumeration Date	:	09/11/2024
Last Update Date	:	09/11/2024

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Directions to “ROOTS4CHANGE COOP ” Practice Location

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