Provider Demographics
NPI:1235866575
Name:LIVING ROOTS WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:LIVING ROOTS WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-930-4848
Mailing Address - Street 1:133 E POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3435
Mailing Address - Country:US
Mailing Address - Phone:208-930-4848
Mailing Address - Fax:844-440-2390
Practice Address - Street 1:133 E POPLAR AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3435
Practice Address - Country:US
Practice Address - Phone:208-930-4848
Practice Address - Fax:844-440-2390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-05
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty