Provider Demographics
NPI:1629737150
Name:RADICAL ROOTS CLINIC LLC
Entity Type:Organization
Organization Name:RADICAL ROOTS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALFORD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:765-267-1177
Mailing Address - Street 1:2046 JONATHAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ARTHUR
Mailing Address - State:IL
Mailing Address - Zip Code:61911-6108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2046 JONATHAN CREEK RD
Practice Address - Street 2:
Practice Address - City:ARTHUR
Practice Address - State:IL
Practice Address - Zip Code:61911-6108
Practice Address - Country:US
Practice Address - Phone:765-267-1177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-13
Last Update Date:2022-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty