Provider Demographics
NPI:1730915190
Name:ROOTS4CHANGE COOP
Entity type:Organization
Organization Name:ROOTS4CHANGE COOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-884-5284
Mailing Address - Street 1:701 E WASHINGTON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2958
Mailing Address - Country:US
Mailing Address - Phone:904-385-8151
Mailing Address - Fax:
Practice Address - Street 1:701 E WASHINGTON AVE STE 102
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2958
Practice Address - Country:US
Practice Address - Phone:904-385-8151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health