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General NPI Number Information
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NPI Number | 1932092178
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Entity Type | Organization
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Legal Business Name | WILD ROOTS OT LLC
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Dates
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Enumeration Date | 05/29/2025
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Last Update Date | 05/29/2025
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Provider Practice Location Address
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Address Line | 1057 OLD OLIVER RD
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City | WALLAND
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State | TN
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Zip | 37886-2338
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Country | US
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Telephone | 865-268-9270
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Fax |
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Provider Business Mailing Address
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Address Line | 1057 OLD OLIVER RD
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City | WALLAND
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State | TN
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Zip | 37886-2338
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Country | US
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Telephone | 239-222-9911
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NICOLE SERAVELLO
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Credential | OTR/L
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Telephone | 239-222-9911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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