Healthcare Provider Details

I. General information

NPI: 1336148279
Provider Name (Legal Business Name): INNOVATIVE PHYSICAL THERAPY SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 CANVASBACK RD
MOORESVILLE NC
28117
US

IV. Provider business mailing address

503 CANVASBACK RD
MOORESVILLE NC
28117
US

V. Phone/Fax

Practice location:
  • Phone: 704-799-9791
  • Fax: 704-799-2687
Mailing address:
  • Phone: 704-799-9791
  • Fax: 704-799-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number6107
License Number StateNC

VIII. Authorized Official

Name: SHIRLEY J DZIKOWSKI
Title or Position: OWNER/DIRECTOR
Credential: PT
Phone: 704-799-9791