Provider Demographics
NPI:1063583516
Name:INNOVATIVE REHAB AND WELLNESS INC
Entity type:Organization
Organization Name:INNOVATIVE REHAB AND WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:TAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-696-4883
Mailing Address - Street 1:575 SARINA TER SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32968-4042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 SARINA TER SW
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32968-4042
Practice Address - Country:US
Practice Address - Phone:772-696-4883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9096225X00000X
FLPT0016300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5608Medicare ID - Type UnspecifiedGROUP NUMBER
FLY08937Medicare UPIN