Provider Demographics
NPI:1679981070
Name:ROOTS HEALTH CLINIC LLC
Entity type:Organization
Organization Name:ROOTS HEALTH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUHN
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-568-1742
Mailing Address - Street 1:330 NE 102ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4107
Mailing Address - Country:US
Mailing Address - Phone:503-252-9181
Mailing Address - Fax:503-252-6161
Practice Address - Street 1:330 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4107
Practice Address - Country:US
Practice Address - Phone:503-252-9181
Practice Address - Fax:503-252-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2013261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care