Provider Demographics
NPI:1952395261
Name:INNOVATIVE ORTHOTICS & REHABILITATION INC
Entity Type:Organization
Organization Name:INNOVATIVE ORTHOTICS & REHABILITATION INC
Other - Org Name:INNOVATIVE ORTHOTICS INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEFRANCIS
Authorized Official - Suffix:
Authorized Official - Credentials:PARTNER
Authorized Official - Phone:404-222-9998
Mailing Address - Street 1:1300 DEKALB AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-2027
Mailing Address - Country:US
Mailing Address - Phone:404-222-9998
Mailing Address - Fax:404-222-9958
Practice Address - Street 1:1300 DEKALB AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-2027
Practice Address - Country:US
Practice Address - Phone:404-222-9998
Practice Address - Fax:404-222-9958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00685121AMedicaid
GA00685121AMedicaid