Healthcare Provider Details

I. General information

NPI: 1417486523
Provider Name (Legal Business Name): INNOVATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3554 PROMENADE PKWY STE H
LAFAYETTE IN
47909-8418
US

IV. Provider business mailing address

3554 PROMENADE PKWY STE H
LAFAYETTE IN
47909-8418
US

V. Phone/Fax

Practice location:
  • Phone: 765-471-1100
  • Fax: 765-471-1009
Mailing address:
  • Phone: 765-471-1100
  • Fax: 765-471-1009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE SNYDER
Title or Position: BILLING MANAGER
Credential:
Phone: 765-413-7100