Provider Demographics
NPI:1871013409
Name:DEEP ROOTS FAMILY MEDICINE
Entity Type:Organization
Organization Name:DEEP ROOTS FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:541-602-7096
Mailing Address - Street 1:605 UNION ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2462
Mailing Address - Country:US
Mailing Address - Phone:971-207-3680
Mailing Address - Fax:503-339-9585
Practice Address - Street 1:605 UNION ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2462
Practice Address - Country:US
Practice Address - Phone:971-207-3680
Practice Address - Fax:503-339-9585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3986101YP2500X
OR1781175F00000X
OR00960175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1083864029OtherNPPES
OR1184647398OtherNPPES
OR1902115215OtherNPPES