MEDICARE: KYLE BERTRAND ROOTSAERT

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	183500000X	Pharmacist	49390	CA

General Provider Information

NPI Number	:	1720416035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE BERTRAND ROOTSAERT

Provider Business Mailing Address
First Line	:	16834 TRAIN STATION CT
Second Line	:
City	:	LATHROP
State	:	CA
Zip	:	95330-8638
Country	:	US
Telephone Number	:	801-885-5959
Fax Number	:

Provider Business Practice Location Address
First Line	:	1906 VISTA DEL LAGO DR STE G
Second Line	:
City	:	VALLEY SPRINGS
State	:	CA
Zip	:	95252-9700
Country	:	US
Telephone Number	:	209-920-3299
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2013
Last Update Date	:	10/23/2013

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Directions to “ KYLE BERTRAND ROOTSAERT ” Practice Location

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