MEDICARE: ROOTED PEDIATRIC HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1548029390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOTED PEDIATRIC HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	715 ANDERSON ST
Second Line	:
City	:	MANCHESTER
State	:	IA
Zip	:	52057-1401
Country	:	US
Telephone Number	:	319-480-2540
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 E BUTLER ST
Second Line	:
City	:	MANCHESTER
State	:	IA
Zip	:	52057-1606
Country	:	US
Telephone Number	:	319-480-2540
Fax Number	:

Authorized Official
Title or Position	:	PEDIATRIC NURSE PRACTITIONER
Name	:	BROOKE ANN MACTAGGART
Credential	:	CPNP-PC
Telephone Number	:	319-480-2540

Provider Enumeration Date	:	03/14/2024
Last Update Date	:	04/22/2024

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