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General NPI Number Information
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NPI Number | 1841644481
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Entity Type | Organization
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Legal Business Name | ROOTS RESIDENTIAL ADULT FAMILY HOMES LLC
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Dates
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Enumeration Date | 04/20/2016
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Last Update Date | 04/20/2016
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Provider Practice Location Address
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Address Line | 1715 LASALLE ST
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City | RACINE
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State | WI
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Zip | 53402-4824
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Country | US
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Telephone | 262-902-3442
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Fax |
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Provider Business Mailing Address
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Address Line | 6210 BLUE RIVER WAY
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City | RACINE
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State | WI
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Zip | 53402-9448
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Country | US
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Telephone | 262-880-5606
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JERODD TAYLOR
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Credential | CPA MBA
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Telephone | 262-880-5606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 0016022
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License Number State | WI
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