Healthcare Provider Details

I. General information

NPI: 1639088131
Provider Name (Legal Business Name): BK ROOTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 HIGHLAND DR
PARK CITY UT
84098-6139
US

IV. Provider business mailing address

633 NH ROUTE 10
ORFORD NH
03777-4109
US

V. Phone/Fax

Practice location:
  • Phone: 801-867-4292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY BRICKER
Title or Position: BILLING SPECIALIST
Credential:
Phone: 603-353-9102