MEDICARE: INNOVATIVE PHYSICAL THERAPY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1825	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1825	OTHER	OR	APTA

General Provider Information

NPI Number	:	1316921646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE PHYSICAL THERAPY, INC

Provider Business Mailing Address
First Line	:	1890 WAITE ST
Second Line	:	SUITE 5
City	:	NORTH BEND
State	:	OR
Zip	:	97459-1229
Country	:	US
Telephone Number	:	541-756-4941
Fax Number	:	541-756-7548

Provider Business Practice Location Address
First Line	:	1890 WAITE ST
Second Line	:	SUITE 5
City	:	NORTH BEND
State	:	OR
Zip	:	97459-1229
Country	:	US
Telephone Number	:	541-756-4941
Fax Number	:	541-756-7548

Authorized Official
Title or Position	:	OWNER
Name	:	MARGARET A COUTTS
Credential	:	PT
Telephone Number	:	541-756-4941

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	06/29/2011

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