=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235866575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING ROOTS WELLNESS CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2022
-----------------------------------------------------
Last Update Date | 08/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 E POPLAR AVE
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-3435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-930-4848
-----------------------------------------------------
Fax | 844-440-2390
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 E POPLAR AVE
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-3435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-930-4848
-----------------------------------------------------
Fax | 844-440-2390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | DR. MELISSA ANNE JACOBSON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 208-930-4848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------