Basic Information
| Provider Information | |||||||||
| NPI: | 1225759160 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVATIVE PHYSICAL THERAPY AND FITNESS CENTERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 WALTER WARD BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210091285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4435128337 | ||||||||
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| Practice Location | |||||||||
| Address1: | 312 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4435128337 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2022 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | MORROW | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4435128337 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSPT | ||||||||
| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.