Healthcare Provider Details

I. General information

NPI: 1992610398
Provider Name (Legal Business Name): RUSTIC ROOTS YOGA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 E CLARK ST STE A
NORTH HAMPTON OH
45349-7511
US

IV. Provider business mailing address

6402 DIALTON RD
SPRINGFIELD OH
45502-9635
US

V. Phone/Fax

Practice location:
  • Phone: 937-471-2515
  • Fax:
Mailing address:
  • Phone: 605-519-4136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHELE L GADDIS
Title or Position: OWNER
Credential: MBA
Phone: 605-519-4136