=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760164990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOTS PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 08/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 W 2ND AVE
-----------------------------------------------------
City | ELLENSBURG
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98926-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-899-0950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 E TACOMA AVE
-----------------------------------------------------
City | ELLENSBURG
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98926-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KAUNG KO
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 509-899-0950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------