Provider Demographics
NPI:1891576591
Name:ROOTED HEALTHCARE, LLC
Entity Type:Organization
Organization Name:ROOTED HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KISUN
Authorized Official - Middle Name:DEVON
Authorized Official - Last Name:PETERS-DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-861-2531
Mailing Address - Street 1:405 N CENTER ST STE 25
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5126
Mailing Address - Country:US
Mailing Address - Phone:917-861-2531
Mailing Address - Fax:
Practice Address - Street 1:1106 BUSINESS PKWY S STE B
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-3054
Practice Address - Country:US
Practice Address - Phone:410-751-7771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Multi-Specialty