Provider Demographics
NPI:1780300806
Name:MOTHERROOT INTEGRATED WELLNESS
Entity type:Organization
Organization Name:MOTHERROOT INTEGRATED WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER/ PA
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:541-414-3808
Mailing Address - Street 1:550 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2926
Mailing Address - Country:US
Mailing Address - Phone:303-325-1550
Mailing Address - Fax:
Practice Address - Street 1:149 CLEAR CREEK DR UNIT 108
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1882
Practice Address - Country:US
Practice Address - Phone:541-414-3808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center