Provider Demographics
NPI:1437632940
Name:COMMON ROOTS LLC
Entity Type:Organization
Organization Name:COMMON ROOTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO -OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-659-5271
Mailing Address - Street 1:805 S TEJON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-4148
Mailing Address - Country:US
Mailing Address - Phone:719-659-5271
Mailing Address - Fax:
Practice Address - Street 1:805 S TEJON ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4148
Practice Address - Country:US
Practice Address - Phone:719-659-5271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care