Healthcare Provider Details

I. General information

NPI: 1770345910
Provider Name (Legal Business Name): WESTERN ROOTS MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E 2ND ST
GRAINFIELD KS
67737-3505
US

IV. Provider business mailing address

PO BOX 21
GRAINFIELD KS
67737-0021
US

V. Phone/Fax

Practice location:
  • Phone: 405-301-2708
  • Fax:
Mailing address:
  • Phone: 785-953-5953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. BROOKE RACHELLE BRIGGS
Title or Position: SOLE MEMBER
Credential: APRN
Phone: 785-953-5953