Provider Demographics
NPI:1770053068
Name:ROOT AND RESTORE THERAPY
Entity type:Organization
Organization Name:ROOT AND RESTORE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIJANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:801-809-2099
Mailing Address - Street 1:3969 S OLYMPIC WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2127
Mailing Address - Country:US
Mailing Address - Phone:801-809-2099
Mailing Address - Fax:
Practice Address - Street 1:4444 S 700 E STE 102
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84107-3075
Practice Address - Country:US
Practice Address - Phone:801-449-0699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy