Provider Demographics
NPI:1215490347
Name:ROOT & BRANCH INTEGRATIVE FITNESS
Entity type:Organization
Organization Name:ROOT & BRANCH INTEGRATIVE FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA PAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:503-577-0318
Mailing Address - Street 1:12575 SW DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-4539
Mailing Address - Country:US
Mailing Address - Phone:503-577-0318
Mailing Address - Fax:503-710-9221
Practice Address - Street 1:1235 SE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3435
Practice Address - Country:US
Practice Address - Phone:503-577-0318
Practice Address - Fax:503-710-9221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROOT & BRANCH PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-06
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty