Provider Demographics
NPI:1972339661
Name:DEEP ROOTS CHIROPRACTIC
Entity type:Organization
Organization Name:DEEP ROOTS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAROD
Authorized Official - Middle Name:
Authorized Official - Last Name:MAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-333-3430
Mailing Address - Street 1:208 S HOLMEN DR STE 104
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-4408
Mailing Address - Country:US
Mailing Address - Phone:608-399-2220
Mailing Address - Fax:
Practice Address - Street 1:208 S HOLMEN DR STE 104
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-4408
Practice Address - Country:US
Practice Address - Phone:608-399-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty