Healthcare Provider Details

I. General information

NPI: 1366214827
Provider Name (Legal Business Name): ROOT AND SOUL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9131 FLETCHER PKWY STE 108
LA MESA CA
91942-3426
US

IV. Provider business mailing address

9131 FLETCHER PKWY STE 108
LA MESA CA
91942-3426
US

V. Phone/Fax

Practice location:
  • Phone: 619-483-1173
  • Fax: 858-365-5157
Mailing address:
  • Phone: 619-483-1173
  • Fax: 858-365-5157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: DR. SHANI COOPER COOPER
Title or Position: CEO
Credential: LAC, DACM
Phone: 619-483-1173