Provider Demographics
NPI:1083858823
Name:ROOTS COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:ROOTS COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERUSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-994-6849
Mailing Address - Street 1:9925 INTERNATIONAL BLVD
Mailing Address - Street 2:#5
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94603-2558
Mailing Address - Country:US
Mailing Address - Phone:510-777-1177
Mailing Address - Fax:
Practice Address - Street 1:9925 INTERNATIONAL BLVD
Practice Address - Street 2:#5
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94603-2558
Practice Address - Country:US
Practice Address - Phone:510-777-1177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No251X00000XAgenciesSupports Brokerage