Healthcare Provider Details

I. General information

NPI: 1053312470
Provider Name (Legal Business Name): INNOVATIVE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HOMESTEAD WAY
RICHMOND ME
04357-3728
US

IV. Provider business mailing address

3 HOMESTEAD WAY
RICHMOND ME
04357-3728
US

V. Phone/Fax

Practice location:
  • Phone: 207-737-7000
  • Fax: 207-737-7028
Mailing address:
  • Phone: 207-737-7000
  • Fax: 207-737-7028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DOREEN HOLMES
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 207-737-7000