Provider Demographics
NPI:1346372588
Name:INNOVATIVE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:INNOVATIVE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:FARAH
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOHARI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:316-612-4900
Mailing Address - Street 1:545 N. CARRIAGE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-4506
Mailing Address - Country:US
Mailing Address - Phone:316-612-4900
Mailing Address - Fax:316-612-4999
Practice Address - Street 1:545 N. CARRIAGE PARKWAY
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4506
Practice Address - Country:US
Practice Address - Phone:316-612-4900
Practice Address - Fax:316-612-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1102277225100000X
KS1103492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100336410BMedicaid
KS=========OtherTAX ID #
KS140292Medicare ID - Type UnspecifiedPRACTICE NUMBER
KS6416180001Medicare NSC