Provider Demographics
NPI:1770003840
Name:INNOVATION THERAPY AND WELLNESS, LLC
Entity Type:Organization
Organization Name:INNOVATION THERAPY AND WELLNESS, LLC
Other - Org Name:FYZICAL THERAPY AND BALANCE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:POSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-245-2855
Mailing Address - Street 1:118 AZALEA RD STE 11
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-9197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 AZALEA RD STE 11
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-9197
Practice Address - Country:US
Practice Address - Phone:912-245-2855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FYZICAL THERAPY AND BALANCE CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty