Provider Demographics
NPI:1679187157
Name:ROOTS CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:ROOTS CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LASHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-320-0853
Mailing Address - Street 1:8112 MINNETONKA BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8112 MINNETONKA BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3022
Practice Address - Country:US
Practice Address - Phone:952-229-4520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6586OtherNON PARTICIPATING
MN6600OtherNON PARTICIPATING