Provider Demographics
NPI:1336827153
Name:ROOTS & WINGS INDEPENDENT LIVING
Entity Type:Organization
Organization Name:ROOTS & WINGS INDEPENDENT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:TISHA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:973-204-7775
Mailing Address - Street 1:10 HEPWORTH PL
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-3206
Mailing Address - Country:US
Mailing Address - Phone:973-204-7775
Mailing Address - Fax:
Practice Address - Street 1:10 HEPWORTH PL
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-3206
Practice Address - Country:US
Practice Address - Phone:973-204-7775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care