Provider Demographics
NPI:1679357685
Name:ROOTED LIFE
Entity type:Organization
Organization Name:ROOTED LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-357-6472
Mailing Address - Street 1:864 GRAND AVE # 802
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3906
Mailing Address - Country:US
Mailing Address - Phone:619-648-1600
Mailing Address - Fax:
Practice Address - Street 1:6315 CONNIE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-2521
Practice Address - Country:US
Practice Address - Phone:619-915-4186
Practice Address - Fax:619-810-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-21
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health