Provider Demographics
NPI:1891842035
Name:INNOVATIONS REHABILITATION, SC
Entity Type:Organization
Organization Name:INNOVATIONS REHABILITATION, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WIEDL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:608-269-0555
Mailing Address - Street 1:501 W WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-2332
Mailing Address - Country:US
Mailing Address - Phone:608-269-0555
Mailing Address - Fax:608-269-6570
Practice Address - Street 1:501 W WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2332
Practice Address - Country:US
Practice Address - Phone:608-269-0555
Practice Address - Fax:608-269-6570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3162-024225100000X
WI4419 - 024225100000X
WI9813 - 024225100000X
WI4051 - 024225100000X
WI92 - 019225200000X
WI798 - 019225200000X
WI44 - 019225200000X
WI817 - 019225200000X
WI4281 - 026225X00000X
WI3666 - 026225X00000X
WI4061 - 026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41220800Medicaid
WI41220800Medicaid