Healthcare Provider Details

I. General information

NPI: 1083858823
Provider Name (Legal Business Name): ROOTS COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9925 INTERNATIONAL BLVD #5
OAKLAND CA
94603-2558
US

IV. Provider business mailing address

9925 INTERNATIONAL BLVD #5
OAKLAND CA
94603-2558
US

V. Phone/Fax

Practice location:
  • Phone: 510-777-1177
  • Fax:
Mailing address:
  • Phone: 510-777-1177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JERUSHA NORMAN
Title or Position: COMPLIANCE ADMINISTRATOR
Credential:
Phone: 510-994-6849