Provider Demographics
NPI:1487071213
Name:LIVING ROOTS LLC
Entity type:Organization
Organization Name:LIVING ROOTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-575-8519
Mailing Address - Street 1:3980 CHICAGO DR SW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1392
Mailing Address - Country:US
Mailing Address - Phone:616-575-8519
Mailing Address - Fax:616-575-9078
Practice Address - Street 1:3980 CHICAGO DR SW
Practice Address - Street 2:SUITE 100
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1392
Practice Address - Country:US
Practice Address - Phone:616-575-8519
Practice Address - Fax:616-575-9078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-18
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health