Provider Demographics
NPI:1184174179
Name:THE ROOT CAUSE CLINIC
Entity type:Organization
Organization Name:THE ROOT CAUSE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AXE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:937-216-9048
Mailing Address - Street 1:15049 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1388
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15049 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-1388
Practice Address - Country:US
Practice Address - Phone:937-216-9048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9255914261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center