Provider Demographics
NPI:1043866460
Name:NORTHERN ROOTS FAMILY SPINAL CARE, LLC
Entity Type:Organization
Organization Name:NORTHERN ROOTS FAMILY SPINAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHASE
Authorized Official - Middle Name:BRENDAN
Authorized Official - Last Name:O'KEEFE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-563-7447
Mailing Address - Street 1:2389 US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54005-7702
Mailing Address - Country:US
Mailing Address - Phone:715-563-7447
Mailing Address - Fax:
Practice Address - Street 1:470 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WI
Practice Address - Zip Code:54005
Practice Address - Country:US
Practice Address - Phone:715-303-7121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty