Provider Demographics
NPI:1407348808
Name:GENTLE ROOTS LLC
Entity Type:Organization
Organization Name:GENTLE ROOTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF ORIENTAL MEDICINE
Authorized Official - Prefix:MS
Authorized Official - First Name:KIRA
Authorized Official - Middle Name:RIO
Authorized Official - Last Name:BOGUSLAW
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:407-803-1890
Mailing Address - Street 1:3040 FOXHILL CIR APT 108
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-8145
Mailing Address - Country:US
Mailing Address - Phone:407-803-1890
Mailing Address - Fax:
Practice Address - Street 1:111 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1301
Practice Address - Country:US
Practice Address - Phone:407-803-1890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3844261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service