Provider Demographics
NPI:1396393369
Name:ROOT MEDICAL
Entity Type:Organization
Organization Name:ROOT MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-789-4483
Mailing Address - Street 1:266 W 100 N STE 2
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2026
Mailing Address - Country:US
Mailing Address - Phone:453-789-4483
Mailing Address - Fax:435-789-4488
Practice Address - Street 1:266 W 100 N STE 2
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2026
Practice Address - Country:US
Practice Address - Phone:453-789-4483
Practice Address - Fax:435-789-4488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty