Provider Demographics
NPI:1578937447
Name:INNOVATIVE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:INNOVATIVE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:219-926-5850
Mailing Address - Street 1:502 E 1100 N
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9697
Mailing Address - Country:US
Mailing Address - Phone:219-926-5850
Mailing Address - Fax:219-250-2072
Practice Address - Street 1:502 E 1100 N
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9697
Practice Address - Country:US
Practice Address - Phone:219-926-5850
Practice Address - Fax:219-250-2072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010042A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty