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General NPI Number Information
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NPI Number | 1770754392
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Entity Type | Organization
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Legal Business Name | ROOTS WELLCARE, P.A.
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Dates
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Enumeration Date | 03/24/2008
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Last Update Date | 12/10/2008
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Provider Practice Location Address
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Address Line | 570 ASBURY STREET SUITE 102
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City | ST PAUL
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State | MN
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Zip | 55104-1852
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Country | US
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Telephone | 651-310-0000
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Fax | 651-389-9491
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Provider Business Mailing Address
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Address Line | 570 ASBURY STREET SUITE 102
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City | ST PAUL
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State | MN
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Zip | 55104-1852
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Country | US
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Telephone | 651-310-0000
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Fax | 651-389-9491
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. CARLA JEAN BREUNIG
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Credential | D.C.
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Telephone | 651-644-0455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 3123
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License Number State | MN
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