Healthcare Provider Details

I. General information

NPI: 1811858962
Provider Name (Legal Business Name): ROOT AND STEM CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2025
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2439 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-4101
US

IV. Provider business mailing address

2439 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-4101
US

V. Phone/Fax

Practice location:
  • Phone: 505-403-6512
  • Fax: 505-403-6512
Mailing address:
  • Phone: 505-403-6512
  • Fax: 505-403-6512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. MICKEY MONDRAGON
Title or Position: CEO
Credential: DC
Phone: 505-403-6512