Provider Demographics
NPI:1366880767
Name:VITAL ROOTS PROF CORP
Entity type:Organization
Organization Name:VITAL ROOTS PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MACKENZIE
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:614-738-8256
Mailing Address - Street 1:4220 SW 104TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98146-1065
Mailing Address - Country:US
Mailing Address - Phone:614-738-8256
Mailing Address - Fax:
Practice Address - Street 1:1225 DEXTER AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-3518
Practice Address - Country:US
Practice Address - Phone:206-497-4962
Practice Address - Fax:206-316-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60181111261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care