MEDICARE: LANDY RYAN ROOT RMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	0014265	CO

General Provider Information

NPI Number	:	1912332735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANDY RYAN ROOT RMT

Provider Business Mailing Address
First Line	:	1920 COLLIER AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-2135
Country	:	US
Telephone Number	:	912-536-6811
Fax Number	:

Provider Business Practice Location Address
First Line	:	1495 GARDEN OF THE GODS RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-9441
Country	:	US
Telephone Number	:	912-536-6811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2013
Last Update Date	:	09/11/2013

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