Provider Demographics
NPI:1568519114
Name:INNISS PHYSICAL THERAPY, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:INNISS PHYSICAL THERAPY, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:BOSWELL
Authorized Official - Last Name:INNISS
Authorized Official - Suffix:
Authorized Official - Credentials:RPT, OCS
Authorized Official - Phone:619-287-4678
Mailing Address - Street 1:6475 ALVARADO RD
Mailing Address - Street 2:#118
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5003
Mailing Address - Country:US
Mailing Address - Phone:619-287-4678
Mailing Address - Fax:619-287-0350
Practice Address - Street 1:6475 ALVARADO RD
Practice Address - Street 2:#118
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5003
Practice Address - Country:US
Practice Address - Phone:619-287-4678
Practice Address - Fax:619-287-0350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW 14455Medicare ID - Type UnspecifiedOUOTPATIENT P.T. CLINIC