Provider Demographics
NPI:1972664712
Name:ROOTS CHIROPRACTIC
Entity Type:Organization
Organization Name:ROOTS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:530-544-7668
Mailing Address - Street 1:PO BOX 1589
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96156-1589
Mailing Address - Country:US
Mailing Address - Phone:530-544-7668
Mailing Address - Fax:
Practice Address - Street 1:3320 SANDY WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-8105
Practice Address - Country:US
Practice Address - Phone:530-544-7668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29850111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty