Healthcare Provider Details

I. General information

NPI: 1891214581
Provider Name (Legal Business Name): ROOTMAMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W WHEATLAND RD STE C
DUNCANVILLE TX
75116-4725
US

IV. Provider business mailing address

PO BOX 151681
ARLINGTON TX
76015-7681
US

V. Phone/Fax

Practice location:
  • Phone: 687-587-7668
  • Fax:
Mailing address:
  • Phone: 682-587-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: FELICIA MONTGOMERY
Title or Position: CEO
Credential: CD
Phone: 682-587-7668