Provider Demographics
NPI:1609594431
Name:GRASSROOTS HEALTH A SOCIAL PURPOSE CORPORATION
Entity Type:Organization
Organization Name:GRASSROOTS HEALTH A SOCIAL PURPOSE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-992-5809
Mailing Address - Street 1:732 PLACER CIR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-7882
Mailing Address - Country:US
Mailing Address - Phone:707-992-5809
Mailing Address - Fax:707-210-0480
Practice Address - Street 1:743 E TABOR AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4046
Practice Address - Country:US
Practice Address - Phone:707-247-2933
Practice Address - Fax:707-210-0480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care