=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609594431
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRASSROOTS HEALTH A SOCIAL PURPOSE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2022
-----------------------------------------------------
Last Update Date | 06/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 97 DOBBINS ST STE A
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95688-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-887-3651
-----------------------------------------------------
Fax | 707-210-0480
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 97 DOBBINS ST STE A
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95688-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-887-3651
-----------------------------------------------------
Fax | 707-210-0480
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | JERRY MICHAEL CLINE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 707-887-3651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA0005X
-----------------------------------------------------
Taxonomy Name | Ambulatory Family Planning Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM1000X
-----------------------------------------------------
Taxonomy Name | Migrant Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------