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General NPI Number Information
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NPI Number | 1972664712
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Entity Type | Organization
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Legal Business Name | ROOTS CHIROPRACTIC
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Dates
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Enumeration Date | 12/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3320 SANDY WAY SUITE 1
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96150-8105
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Country | US
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Telephone | 530-544-7668
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1589
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96156-1589
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Country | US
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Telephone | 530-544-7668
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | BERNADETTE GONZALES
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Credential | DC
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Telephone | 530-544-7668
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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 | DC29850
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License Number State | CA
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