MEDICARE: INNOVATIVE PHYSICAL THERAPY LLC

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	4686	CO

General Provider Information

NPI Number	:	1831341338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	5350 MANHATTAN CIR STE 100
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-4272
Country	:	US
Telephone Number	:	303-543-1201
Fax Number	:	303-543-1206

Provider Business Practice Location Address
First Line	:	5350 MANHATTAN CIR STE 100
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-4272
Country	:	US
Telephone Number	:	303-543-1201
Fax Number	:	303-543-1206

Authorized Official
Title or Position	:	PT/OWNER
Name	:	JULIE V EDELMAN
Credential	:	PT
Telephone Number	:	303-543-1201

Provider Enumeration Date	:	10/15/2008
Last Update Date	:	02/06/2009

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