1770675712 NPI number — INNOVO HEALTHCARE, LLC

Table of content: (NPI 1770675712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770675712 NPI number — INNOVO HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVO HEALTHCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770675712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 COMMERCE DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54016-8278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-377-9617
Provider Business Mailing Address Fax Number:
715-377-9623

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 COMMERCE DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54016-8278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-377-9617
Provider Business Practice Location Address Fax Number:
715-377-9623
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
ERIK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
715-377-9617

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1050 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 43113900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1050 . This is a "STATE REGULAR HOME HEALTH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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