Provider Demographics
NPI:1225048887
Name:INNOVATIVE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:INNOVATIVE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:NEPHEW
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:361-855-8004
Mailing Address - Street 1:4455 SPID SUITE 8
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411
Mailing Address - Country:US
Mailing Address - Phone:361-855-8004
Mailing Address - Fax:361-986-0751
Practice Address - Street 1:1605 E DEL MAR BLVD STE 14
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6517
Practice Address - Country:US
Practice Address - Phone:956-725-2882
Practice Address - Fax:956-725-2880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPT11145852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP78693Medicare UPIN
TX8A3060Medicare ID - Type Unspecified