MEDICARE: ROOTS WELLCARE, P.A.

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	111N00000X	Chiropractor	3123	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3123	OTHER	MN	CHIROPRACTIC LICENSE NO.
3	4C181BR	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1770754392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOTS WELLCARE, P.A.

Provider Business Mailing Address
First Line	:	570 ASBURY STREET
Second Line	:	SUITE 102
City	:	ST PAUL
State	:	MN
Zip	:	55104-1852
Country	:	US
Telephone Number	:	651-310-0000
Fax Number	:	651-389-9491

Provider Business Practice Location Address
First Line	:	570 ASBURY STREET
Second Line	:	SUITE 102
City	:	ST PAUL
State	:	MN
Zip	:	55104-1852
Country	:	US
Telephone Number	:	651-310-0000
Fax Number	:	651-389-9491

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. CARLA JEAN BREUNIG
Credential	:	D.C.
Telephone Number	:	651-644-0455

Provider Enumeration Date	:	03/24/2008
Last Update Date	:	12/10/2008

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Directions to “ROOTS WELLCARE, P.A. ” Practice Location

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