Provider Demographics
NPI:1437629128
Name:ROOT FUNCTION WELLNESS PLLC
Entity Type:Organization
Organization Name:ROOT FUNCTION WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-880-0679
Mailing Address - Street 1:6554 9TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-7099
Mailing Address - Country:US
Mailing Address - Phone:605-880-0679
Mailing Address - Fax:
Practice Address - Street 1:2320 9TH AVE SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-7112
Practice Address - Country:US
Practice Address - Phone:605-753-0920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1376554568Medicaid