Provider Demographics
NPI:1215385042
Name:TRADITIONAL ROOTS HEALTHCARE
Entity Type:Organization
Organization Name:TRADITIONAL ROOTS HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERBY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:651-447-2196
Mailing Address - Street 1:165 DUNLAP STREET
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-447-2196
Mailing Address - Fax:
Practice Address - Street 1:165 DUNLAP ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6405
Practice Address - Country:US
Practice Address - Phone:651-447-2196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1774171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty