Provider Demographics
NPI:1831986629
Name:ROOT JR, ELOISE
Entity type:Individual
Prefix:
First Name:ELOISE
Middle Name:
Last Name:ROOT JR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2326 SW GLACIER PL
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-7626
Mailing Address - Country:US
Mailing Address - Phone:541-516-0669
Mailing Address - Fax:541-516-0669
Practice Address - Street 1:2326 SW GLACIER PL
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-7626
Practice Address - Country:US
Practice Address - Phone:541-516-0669
Practice Address - Fax:541-516-0669
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR113842175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist