Provider Demographics
NPI:1063805752
Name:ROOTS MEDICAL, LLC
Entity type:Organization
Organization Name:ROOTS MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:DARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-729-0108
Mailing Address - Street 1:6091 S QUEBEC ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80111
Mailing Address - Country:US
Mailing Address - Phone:720-390-5148
Mailing Address - Fax:720-729-0108
Practice Address - Street 1:6091 S QUEBEC ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111
Practice Address - Country:US
Practice Address - Phone:720-390-5148
Practice Address - Fax:720-729-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty