=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154246627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSTIC ROOTS YOGA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2026
-----------------------------------------------------
Last Update Date | 08/12/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 E CLARK ST STE A
-----------------------------------------------------
City | NORTH HAMPTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45349-7511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-519-4136
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6402 DIALTON RD
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45502-9635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-519-4136
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHELE L GADDIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-519-4136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225600000X
-----------------------------------------------------
Taxonomy Name | Dance Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------