Provider Demographics
NPI:1972290500
Name:ROOT OF WELLNESS CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ROOT OF WELLNESS CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLI
Authorized Official - Middle Name:M
Authorized Official - Last Name:VANGOETHEM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-621-1854
Mailing Address - Street 1:402 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1329
Mailing Address - Country:US
Mailing Address - Phone:920-388-4499
Mailing Address - Fax:
Practice Address - Street 1:402 ELLIS ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1329
Practice Address - Country:US
Practice Address - Phone:920-388-4499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty