Provider Demographics
NPI:1720966674
Name:GOLDEN ROOTS WELLNESS GROUP INC
Entity type:Organization
Organization Name:GOLDEN ROOTS WELLNESS GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TREVYON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-551-5794
Mailing Address - Street 1:2580 W CAMP WISDOM RD STE 100-176
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3088
Mailing Address - Country:US
Mailing Address - Phone:469-551-5794
Mailing Address - Fax:
Practice Address - Street 1:700 S COCKRELL HILL RD STE 158
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-2632
Practice Address - Country:US
Practice Address - Phone:469-222-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals