Healthcare Provider Details

I. General information

NPI: 1437620937
Provider Name (Legal Business Name): ROOTS FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2018
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 NE DOCTORS DR STE 1A
BEND OR
97701
US

IV. Provider business mailing address

2275 NE DOCTORS DR STE 1A
BEND OR
97701-6324
US

V. Phone/Fax

Practice location:
  • Phone: 541-241-2656
  • Fax: 541-241-9848
Mailing address:
  • Phone: 541-241-2656
  • Fax: 541-241-9848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHANNA GEIGLE
Title or Position: OWNER
Credential: NP
Phone: 503-475-9650