Healthcare Provider Details

I. General information

NPI: 1780375675
Provider Name (Legal Business Name): ROOTS LIFESTYLE MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 ALYSHEBA WAY STE 1001A
LEXINGTON KY
40509-2282
US

IV. Provider business mailing address

1795 ALYSHEBA WAY STE 1001A
LEXINGTON KY
40509-2282
US

V. Phone/Fax

Practice location:
  • Phone: 859-229-3329
  • Fax: 855-921-1840
Mailing address:
  • Phone: 859-229-3329
  • Fax: 855-921-1840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: STEVI MCDONALD
Title or Position: ADMINISTRATOR
Credential:
Phone: 859-492-8509