Provider Demographics
NPI:1770754392
Name:ROOTS WELLCARE, P.A.
Entity type:Organization
Organization Name:ROOTS WELLCARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BREUNIG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-644-0455
Mailing Address - Street 1:570 ASBURY STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1852
Mailing Address - Country:US
Mailing Address - Phone:651-310-0000
Mailing Address - Fax:651-389-9491
Practice Address - Street 1:570 ASBURY STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1852
Practice Address - Country:US
Practice Address - Phone:651-310-0000
Practice Address - Fax:651-389-9491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3123111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN465860400Medicaid
MN3123OtherCHIROPRACTIC LICENSE NO.
MN4C181BROtherBLUE CROSS BLUE SHIELD
MN350002980Medicare PIN
MN465860400Medicaid