Healthcare Provider Details

I. General information

NPI: 1407229750
Provider Name (Legal Business Name): ROOTS MIDWIFERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 44TH AVE N
MINNEAPOLIS MN
55412-1209
US

IV. Provider business mailing address

1901 44TH AVE N
MINNEAPOLIS MN
55412-1209
US

V. Phone/Fax

Practice location:
  • Phone: 612-338-2784
  • Fax:
Mailing address:
  • Phone: 612-338-2784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELANIE GRAY
Title or Position: BILLER, OFFICE ADMIN
Credential:
Phone: 651-328-7699