Provider Demographics
NPI:1821486481
Name:INNOVA PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:INNOVA PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:REGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:518-632-4944
Mailing Address - Street 1:357 BAY RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-3050
Mailing Address - Country:US
Mailing Address - Phone:518-632-4944
Mailing Address - Fax:518-632-4945
Practice Address - Street 1:357 BAY RD
Practice Address - Street 2:SUITE 4
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-3050
Practice Address - Country:US
Practice Address - Phone:518-632-4944
Practice Address - Fax:518-632-4945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0254361261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy