Provider Demographics
NPI:1891214581
Name:ROOTMAMA LLC
Entity Type:Organization
Organization Name:ROOTMAMA LLC
Other - Org Name:ROOTMAMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:CD
Authorized Official - Phone:682-587-7668
Mailing Address - Street 1:PO BOX 151681
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-7681
Mailing Address - Country:US
Mailing Address - Phone:682-587-7668
Mailing Address - Fax:
Practice Address - Street 1:119 W WHEATLAND RD STE C
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4725
Practice Address - Country:US
Practice Address - Phone:687-587-7668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty