Provider Demographics
NPI:1821047580
Name:INNOVATIVE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:INNOVATIVE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:619-260-0750
Mailing Address - Street 1:5030 CAMINO DE LA SIESTA
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3116
Mailing Address - Country:US
Mailing Address - Phone:619-260-0750
Mailing Address - Fax:619-260-0201
Practice Address - Street 1:5030 CAMINO DE LA SIESTA
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3116
Practice Address - Country:US
Practice Address - Phone:619-260-0750
Practice Address - Fax:619-260-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT122942251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19864Medicare PIN