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General NPI Number Information
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NPI Number | 1821486481
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Entity Type | Organization
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Legal Business Name | INNOVA PHYSICAL THERAPY, PLLC
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Dates
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Enumeration Date | 01/06/2015
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Last Update Date | 01/06/2015
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Provider Practice Location Address
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Address Line | 357 BAY RD SUITE 4
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City | QUEENSBURY
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State | NY
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Zip | 12804-3050
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Country | US
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Telephone | 518-632-4944
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Fax | 518-632-4945
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Provider Business Mailing Address
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Address Line | 357 BAY RD SUITE 4
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City | QUEENSBURY
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State | NY
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Zip | 12804-3050
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Country | US
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Telephone | 518-632-4944
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Fax | 518-632-4945
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Authorized Official
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Title or Position | OWNER
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Name | SHANNON REGNER
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Credential | PT
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Telephone | 518-632-4944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 0254361
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License Number State | NY
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