Healthcare Provider Details

I. General information

NPI: 1760174288
Provider Name (Legal Business Name): NICOLE RODA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 HARVE AVE # 2
MISSOULA MT
59801-8344
US

IV. Provider business mailing address

1940 HARVE AVE # 2
MISSOULA MT
59801-8344
US

V. Phone/Fax

Practice location:
  • Phone: 406-542-0808
  • Fax: 406-542-0909
Mailing address:
  • Phone: 406-542-0808
  • Fax: 406-542-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTP-PT-LIC-27061
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: