Provider Demographics
NPI:1740548742
Name:INNOVATIVE PHYSICAL THERAPY AND FITNESS CENTER INC
Entity type:Organization
Organization Name:INNOVATIVE PHYSICAL THERAPY AND FITNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:
Authorized Official - Last Name:BABU
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT,MS
Authorized Official - Phone:732-853-8177
Mailing Address - Street 1:3562 ROUTE 27
Mailing Address - Street 2:SUITE 124
Mailing Address - City:KENDALL PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08824
Mailing Address - Country:US
Mailing Address - Phone:732-853-8177
Mailing Address - Fax:
Practice Address - Street 1:3562 ROUTE 27
Practice Address - Street 2:SUITE 124
Practice Address - City:KENDALL PARK
Practice Address - State:NJ
Practice Address - Zip Code:08824
Practice Address - Country:US
Practice Address - Phone:732-853-8177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01115800261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
180947DBDOtherMEDICARE