Provider Demographics
NPI:1093103814
Name:ROOTS MIDWIFERY, LLC
Entity Type:Organization
Organization Name:ROOTS MIDWIFERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MIDWIFE
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:CPM
Authorized Official - Phone:612-963-7770
Mailing Address - Street 1:302 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7721
Mailing Address - Country:US
Mailing Address - Phone:612-963-7770
Mailing Address - Fax:612-223-6799
Practice Address - Street 1:302 7TH ST S
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-7721
Practice Address - Country:US
Practice Address - Phone:612-963-7770
Practice Address - Fax:612-223-6799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty