Healthcare Provider Details

I. General information

NPI: 1861864456
Provider Name (Legal Business Name): INNOVATION HEALTHCARE SYSTEMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11680 GREAT OAKS WAY SUITE 150
ALPHARETTA GA
30022-2457
US

IV. Provider business mailing address

PO BOX 147
DEMOREST GA
30535-0147
US

V. Phone/Fax

Practice location:
  • Phone: 706-778-0077
  • Fax:
Mailing address:
  • Phone: 706-778-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR008431
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number003705
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN202988
License Number StateGA

VIII. Authorized Official

Name: MR. COURTNEY A MOTE
Title or Position: OWNER
Credential: DC
Phone: 706-778-0077