Healthcare Provider Details

I. General information

NPI: 1437632940
Provider Name (Legal Business Name): COMMON ROOTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 S TEJON ST
COLORADO SPRINGS CO
80903-4148
US

IV. Provider business mailing address

805 S TEJON ST
COLORADO SPRINGS CO
80903-4148
US

V. Phone/Fax

Practice location:
  • Phone: 719-659-5271
  • Fax:
Mailing address:
  • Phone: 719-659-5271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: TRACY L BROWN
Title or Position: CO -OWNER
Credential:
Phone: 719-659-5271