Healthcare Provider Details

I. General information

NPI: 1790396372
Provider Name (Legal Business Name): ROOTED REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2020
Last Update Date: 08/16/2020
Certification Date: 08/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 E VICTORIA ST UNIT 609
CARSON CA
90746-1558
US

IV. Provider business mailing address

849 E VICTORIA ST UNIT 609
CARSON CA
90746-1558
US

V. Phone/Fax

Practice location:
  • Phone: 310-753-7500
  • Fax:
Mailing address:
  • Phone: 310-753-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. CALVIN DIVINITY II
Title or Position: CEO
Credential: DPT
Phone: 310-753-7500