Healthcare Provider Details

I. General information

NPI: 1578937447
Provider Name (Legal Business Name): INNOVATIVE PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 E 1100 N
CHESTERTON IN
46304-9697
US

IV. Provider business mailing address

502 E 1100 N
CHESTERTON IN
46304-9697
US

V. Phone/Fax

Practice location:
  • Phone: 219-926-5850
  • Fax: 219-250-2072
Mailing address:
  • Phone: 219-926-5850
  • Fax: 219-250-2072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05010042A
License Number StateIN

VIII. Authorized Official

Name: DR. KEITH ELLIS
Title or Position: OWNER
Credential: DPT
Phone: 219-926-5850