Provider Demographics
NPI:1073232658
Name:INNOVATIVE PHYSICAL THERAPY & WELLNESS, LLC
Entity type:Organization
Organization Name:INNOVATIVE PHYSICAL THERAPY & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:TRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:920-770-4150
Mailing Address - Street 1:715 SUPERIOR RD STE 103
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7595
Mailing Address - Country:US
Mailing Address - Phone:920-770-4150
Mailing Address - Fax:920-770-4149
Practice Address - Street 1:715 SUPERIOR RD STE 103
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7595
Practice Address - Country:US
Practice Address - Phone:920-770-4150
Practice Address - Fax:920-770-4149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy