MEDICARE: ROOTS CHIROPRACTIC

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	DC29850	CA

General Provider Information

NPI Number	:	1972664712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOTS CHIROPRACTIC

Provider Business Mailing Address
First Line	:	PO BOX 1589
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96156-1589
Country	:	US
Telephone Number	:	530-544-7668
Fax Number	:

Provider Business Practice Location Address
First Line	:	3320 SANDY WAY
Second Line	:	SUITE 1
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-8105
Country	:	US
Telephone Number	:	530-544-7668
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	BERNADETTE GONZALES
Credential	:	DC
Telephone Number	:	530-544-7668

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	08/22/2020

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Directions to “ROOTS CHIROPRACTIC ” Practice Location

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