Provider Demographics
NPI:1073364469
Name:MOUNTAIN ROOTED BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:MOUNTAIN ROOTED BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:RENDON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-731-0991
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-0091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 LOCKHEED DR
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813-8962
Practice Address - Country:US
Practice Address - Phone:304-253-5155
Practice Address - Fax:681-207-7011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty