Healthcare Provider Details

I. General information

NPI: 1124934948
Provider Name (Legal Business Name): RUSTIC ROOTS FAMILY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 HERITAGE BLVD
LONGVIEW TX
75605-1472
US

IV. Provider business mailing address

PO BOX 162
WHITE OAK TX
75693-0162
US

V. Phone/Fax

Practice location:
  • Phone: 903-228-2728
  • Fax:
Mailing address:
  • Phone: 903-228-2728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CARL CINI
Title or Position: PRESIDENT
Credential:
Phone: 903-228-2728