=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083258461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOTED COMMUNITY ACUPUNCTURE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2019
-----------------------------------------------------
Last Update Date | 05/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3133 E GREENWAY RD STE 505
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-4480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-336-3504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12810 N 29TH ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-758-1235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | SAJA LYNN
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 480-336-3504
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------