Provider Demographics
NPI:1518515956
Name:WELL ROOTED HEALTH AND NUTRITION
Entity Type:Organization
Organization Name:WELL ROOTED HEALTH AND NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:UMO
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD/LD, CSSD, CPT
Authorized Official - Phone:405-837-7003
Mailing Address - Street 1:16404 JOSIAH PL
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-9730
Mailing Address - Country:US
Mailing Address - Phone:405-837-7003
Mailing Address - Fax:
Practice Address - Street 1:3330 NW 56TH ST STE 608
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4470
Practice Address - Country:US
Practice Address - Phone:405-885-0270
Practice Address - Fax:405-300-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200398760AMedicaid