Healthcare Provider Details

I. General information

NPI: 1962263871
Provider Name (Legal Business Name): MIXED ROOTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/18/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 CREEDMOOR RD STE 118
RALEIGH NC
27612-6730
US

IV. Provider business mailing address

10624 SUNNY POINT DR
ZEBULON NC
27597-6880
US

V. Phone/Fax

Practice location:
  • Phone: 919-720-4080
  • Fax:
Mailing address:
  • Phone: 856-236-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA MCCRAY
Title or Position: SALON OWNER
Credential: STYLIST
Phone: 856-236-6555