Provider Demographics
NPI:1548029390
Name:ROOTED PEDIATRIC HEALTHCARE LLC
Entity type:Organization
Organization Name:ROOTED PEDIATRIC HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MACTAGGART
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP-PC
Authorized Official - Phone:319-480-2540
Mailing Address - Street 1:715 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-1401
Mailing Address - Country:US
Mailing Address - Phone:319-480-2540
Mailing Address - Fax:
Practice Address - Street 1:105 E BUTLER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1606
Practice Address - Country:US
Practice Address - Phone:319-480-2540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-14
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty