Healthcare Provider Details

I. General information

NPI: 1740891084
Provider Name (Legal Business Name): ROOT CAUSE MEDICAL CLINIC CLW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S FORT HARRISON AVE
CLEARWATER FL
33756-3934
US

IV. Provider business mailing address

20398 BLAUER DR
SARATOGA CA
95070-4307
US

V. Phone/Fax

Practice location:
  • Phone: 727-335-0400
  • Fax:
Mailing address:
  • Phone: 408-733-0400
  • Fax: 408-733-4388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. PAULA SUE SANCHEZ
Title or Position: DIRECTOR OF TREATMENT FINANCE
Credential: CPC-A
Phone: 408-733-0400