Healthcare Provider Details

I. General information

NPI: 1689703191
Provider Name (Legal Business Name): LIFEROOTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 04/25/2025
Certification Date:
Deactivation Date: 02/27/2025
Reactivation Date: 04/25/2025

III. Provider practice location address

1111 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1614
US

IV. Provider business mailing address

1111 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1614
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5501
  • Fax: 505-255-9971
Mailing address:
  • Phone: 505-255-5501
  • Fax: 505-255-9971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number01771248
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License NumberPENDING
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberPENDING
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPENDING
License Number StateNM

VIII. Authorized Official

Name: MS. KATHLEEN MARY CATES
Title or Position: CEO/PRESIDENT
Credential:
Phone: 505-255-5501