Provider Demographics
NPI:1164899373
Name:ROOT & BRANCH PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:ROOT & BRANCH PHYSICAL THERAPY LLC
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:DELAPAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:503-577-0318
Mailing Address - Street 1:1235 SE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3435
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:503-308-9504
Practice Address - Fax:503-710-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60188225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1114350899OtherTYPE 1 NPI
OR500697684Medicaid
OR1255888483OtherTYPE 1 NPI
R186858Medicare PIN