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General NPI Number Information
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NPI Number | 1679843700
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Entity Type | Organization
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Legal Business Name | GRASS ROOTS HEALTH FOODS
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Dates
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Enumeration Date | 01/05/2012
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 3440 STATE HIGHWAY 70 E
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City | EAGLE RIVER
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State | WI
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Zip | 54521-9491
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Country | US
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Telephone | 715-479-6299
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Fax |
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Provider Business Mailing Address
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Address Line | 3440 STATE HIGHWAY 70 E
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City | EAGLE RIVER
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State | WI
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Zip | 54521-9491
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. DAVID G. KOLLER
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Credential |
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Telephone | 715-479-6299
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335G00000X
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Taxonomy Name | Medical Foods Supplier
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License Number |
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License Number State | WI
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