Provider Demographics
NPI:1770345910
Name:WESTERN ROOTS MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:WESTERN ROOTS MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:RACHELLE
Authorized Official - Last Name:BRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:785-953-5953
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:GRAINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67737-0021
Mailing Address - Country:US
Mailing Address - Phone:785-953-5953
Mailing Address - Fax:
Practice Address - Street 1:123 E 2ND ST
Practice Address - Street 2:
Practice Address - City:GRAINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67737-3505
Practice Address - Country:US
Practice Address - Phone:405-301-2708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-24
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty