Provider Demographics
NPI:1861860090
Name:ROOT OF MEDICINE, PLLC
Entity Type:Organization
Organization Name:ROOT OF MEDICINE, PLLC
Other - Org Name:REBEL MED NORTHWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:206-206-2976
Mailing Address - Street 1:5401 LEARY AVE NW STE 202
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4070
Mailing Address - Country:US
Mailing Address - Phone:206-206-2976
Mailing Address - Fax:206-582-3472
Practice Address - Street 1:5401 LEARY AVE NW STE 202
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4070
Practice Address - Country:US
Practice Address - Phone:206-206-2976
Practice Address - Fax:206-582-3472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60412804175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2035017Medicaid
WA2096495Medicaid