Provider Demographics
NPI:1831778539
Name:NEW ROOTS, LLC
Entity type:Organization
Organization Name:NEW ROOTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANN
Authorized Official - Suffix:
Authorized Official - Credentials:OTD, OTR/L
Authorized Official - Phone:907-531-9202
Mailing Address - Street 1:1681 WOLVERINE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-6630
Mailing Address - Country:US
Mailing Address - Phone:907-378-4833
Mailing Address - Fax:
Practice Address - Street 1:3535 COLLEGE RD STE 211
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3724
Practice Address - Country:US
Practice Address - Phone:907-531-9202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-08
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service