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General NPI Number Information
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NPI Number | 1124764782
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Entity Type | Organization
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Legal Business Name | INNOVATIVE OT NC LLC
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Dates
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Enumeration Date | 05/06/2022
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 412 FIRE OPAL LANE
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City | HOLLY SPRINGS
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State | NC
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Zip | 27540
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Country | US
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Telephone | 919-244-8367
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Fax |
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Provider Business Mailing Address
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Address Line | 644 HOLLY SPRINGS RD STE 148
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City | HOLLY SPRINGS
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State | NC
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Zip | 27540-9030
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Country | US
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Telephone | 919-244-8367
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KAREN TRACY JOHNSON
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Credential | OT
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Telephone | 919-244-8367
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0019X
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Taxonomy Name | Physical Rehabilitation Occupational Therapist
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License Number |
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License Number State |
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