| Organization Name: | FRESH ROOTS, INC. |
| NPI Number: | 1053479634 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DELL CHRISTY TYSON (CO-DIRECTOR) |
| Mailing Address: | 318 W Poplar St Rogers |
| State: | AR US |
| Postal Code: | 727564559 |
| Phone Number: | 4799868655 |
| Fax Number: | 4796339398 |
| NPI Enumeration Date: | 12/05/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | P9201002 |
| Healthcare Provider Taxonomy: (Secondary) | X |
| State: | AR |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |