Healthcare Provider Details

I. General information

NPI: 1023064805
Provider Name (Legal Business Name): THERAPEUTIC INNOVATIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W THIRD ST
BROOKSTON IN
47623-0404
US

IV. Provider business mailing address

111 W THIRD ST PO BOX 404
BROOKSTON IN
47623-0404
US

V. Phone/Fax

Practice location:
  • Phone: 765-563-6868
  • Fax:
Mailing address:
  • Phone: 765-563-6868
  • Fax: 765-563-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05000581A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31000116A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number69000280A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: LENARD MILLER
Title or Position: VICE PRESIDENT
Credential:
Phone: 765-563-6868