1790327666 NPI number — INNOVATION HEALTHCARE SOLUTION, PLLC

Table of content: (NPI 1790327666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790327666 NPI number — INNOVATION HEALTHCARE SOLUTION, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATION HEALTHCARE SOLUTION, PLLC
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:
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:
1790327666
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3837 CRUSADE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27101-2252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-986-3046
Provider Business Mailing Address Fax Number:
877-445-5698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 VEST MILL RD STE 33
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-2978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-934-5354
Provider Business Practice Location Address Fax Number:
877-445-5698
Provider Enumeration Date:
10/11/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
KATETIA
Authorized Official Middle Name:
Authorized Official Title or Position:
AGENCY DIRECTOR
Authorized Official Telephone Number:
336-986-3046

Provider Taxonomy Codes

  • Taxonomy code: 251F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 376K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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