Provider Demographics
NPI:1841644481
Name:ROOTS RESIDENTIAL ADULT FAMILY HOMES LLC
Entity type:Organization
Organization Name:ROOTS RESIDENTIAL ADULT FAMILY HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERODD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CPA MBA
Authorized Official - Phone:262-880-5606
Mailing Address - Street 1:6210 BLUE RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-9448
Mailing Address - Country:US
Mailing Address - Phone:262-880-5606
Mailing Address - Fax:
Practice Address - Street 1:1715 LASALLE ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-4824
Practice Address - Country:US
Practice Address - Phone:262-902-3442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0016022261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center