Provider Demographics
NPI:1396027629
Name:ROOTS WHOLISTIC HEALTH
Entity type:Organization
Organization Name:ROOTS WHOLISTIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:CHRISTINE BROOKS
Authorized Official - Last Name:MCPEAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-258-7001
Mailing Address - Street 1:717 CHURCHILL ST.
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981
Mailing Address - Country:US
Mailing Address - Phone:715-258-7001
Mailing Address - Fax:715-258-7048
Practice Address - Street 1:717 CHURCHILL ST.
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981
Practice Address - Country:US
Practice Address - Phone:715-258-7001
Practice Address - Fax:715-258-7048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4760-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty