Provider Demographics
NPI:1922580901
Name:DEEP ROOTS HEALTH CENTER INC
Entity Type:Organization
Organization Name:DEEP ROOTS HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:479-595-8022
Mailing Address - Street 1:103 SW WINSTED LN STE 25
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72713-6203
Mailing Address - Country:US
Mailing Address - Phone:479-595-8022
Mailing Address - Fax:
Practice Address - Street 1:103 SW WINSTED LN STE 25
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72713-6203
Practice Address - Country:US
Practice Address - Phone:479-595-8022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty