Provider Demographics
NPI:1740990928
Name:ROOTS OF ADDICTION COUNSELING CENTER LLC
Entity type:Organization
Organization Name:ROOTS OF ADDICTION COUNSELING CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RAESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-758-7477
Mailing Address - Street 1:1101 SYLVAN AVE STE C103
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1687
Mailing Address - Country:US
Mailing Address - Phone:209-578-7477
Mailing Address - Fax:
Practice Address - Street 1:1101 SYLVAN AVE STE C103
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1687
Practice Address - Country:US
Practice Address - Phone:209-578-7477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1306952
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-29
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty