Healthcare Provider Details

I. General information

NPI: 1700642329
Provider Name (Legal Business Name): BLVK2ROOTS HOLISTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 INTERNATIONAL BLVD
OAKLAND CA
94606-3727
US

IV. Provider business mailing address

937 INTERNATIONAL BLVD
OAKLAND CA
94606-3727
US

V. Phone/Fax

Practice location:
  • Phone: 628-333-0585
  • Fax:
Mailing address:
  • Phone: 628-333-0585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: DAMON KINARD
Title or Position: OWNER
Credential: DOULA,MSCNM,CHHC,CWC
Phone: 628-333-0585