Provider Demographics
NPI:1912100165
Name:INNOVATIVE THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:INNOVATIVE THERAPY SERVICES, LLC
Other - Org Name:MOBILE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:ABRAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:314-255-9749
Mailing Address - Street 1:1310 PAPIN ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-3132
Mailing Address - Country:US
Mailing Address - Phone:315-558-1385
Mailing Address - Fax:314-335-7770
Practice Address - Street 1:1310 PAPIN ST
Practice Address - Street 2:SUITE 109
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-3132
Practice Address - Country:US
Practice Address - Phone:315-558-1385
Practice Address - Fax:314-335-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005012155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504583105Medicaid
MO504583105Medicaid