Provider Demographics
NPI:1346790110
Name:ROOTS RESIDENTIAL ADULT FAMILY HOME LLC
Entity Type:Organization
Organization Name:ROOTS RESIDENTIAL ADULT FAMILY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERODD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MBA CPA
Authorized Official - Phone:262-880-5606
Mailing Address - Street 1:PO BOX 44035
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-7001
Mailing Address - Country:US
Mailing Address - Phone:262-880-5606
Mailing Address - Fax:262-383-2131
Practice Address - Street 1:1715 LASALLE ST UPPR
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-4824
Practice Address - Country:US
Practice Address - Phone:262-800-1457
Practice Address - Fax:262-383-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0016034311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home