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General NPI Number Information
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NPI Number | 1548029390
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Entity Type | Organization
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Legal Business Name | ROOTED PEDIATRIC HEALTHCARE LLC
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Dates
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Enumeration Date | 03/14/2024
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Last Update Date | 04/22/2024
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Provider Practice Location Address
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Address Line | 105 E BUTLER ST
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City | MANCHESTER
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State | IA
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Zip | 52057-1606
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Country | US
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Telephone | 319-480-2540
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Fax |
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Provider Business Mailing Address
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Address Line | 715 ANDERSON ST
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City | MANCHESTER
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State | IA
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Zip | 52057-1401
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Country | US
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Telephone | 319-480-2540
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC NURSE PRACTITIONER
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Name | BROOKE ANN MACTAGGART
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Credential | CPNP-PC
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Telephone | 319-480-2540
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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