Provider Demographics
NPI:1679307748
Name:ROOTS PEDIATRIC PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:ROOTS PEDIATRIC PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:BOBLETT
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:336-288-6330
Mailing Address - Street 1:3033 VINCENT ASTOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:JOHN'S ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-8279
Mailing Address - Country:US
Mailing Address - Phone:336-288-6330
Mailing Address - Fax:
Practice Address - Street 1:3033 VINCENT ASTOR DRIVE
Practice Address - Street 2:
Practice Address - City:JOHN'S ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-8279
Practice Address - Country:US
Practice Address - Phone:336-288-6330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH5083Medicaid