Provider Demographics
NPI:1245007095
Name:DEEP ROOTS LLC
Entity type:Organization
Organization Name:DEEP ROOTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COLE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-895-4353
Mailing Address - Street 1:1351 PAGE DR S STE 200
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3536
Mailing Address - Country:US
Mailing Address - Phone:701-895-4353
Mailing Address - Fax:
Practice Address - Street 1:1351 PAGE DR S STE 200
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3536
Practice Address - Country:US
Practice Address - Phone:701-895-4353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-11
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty