Healthcare Provider Details

I. General information

NPI: 1619709938
Provider Name (Legal Business Name): PAMOJA ROOTED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7722 CAPRON CT
LORTON VA
22079-4346
US

IV. Provider business mailing address

7722 CAPRON CT
LORTON VA
22079-4346
US

V. Phone/Fax

Practice location:
  • Phone: 630-518-0909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: CHARDONEE DONALD
Title or Position: CERTIFIED NUTRITION SPECIALIST
Credential: CNS, LDN
Phone: 630-518-0909