Healthcare Provider Details

I. General information

NPI: 1134821309
Provider Name (Legal Business Name): INNOVATIVE INFUSIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12669 OLIVE BLVD STE A
SAINT LOUIS MO
63141-6333
US

IV. Provider business mailing address

3033 W PRESIDENT GEORGE BUSH HWY STE 100
PLANO TX
75075-5752
US

V. Phone/Fax

Practice location:
  • Phone: 314-710-5021
  • Fax:
Mailing address:
  • Phone: 972-588-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMY MULDERRY
Title or Position: PRESIDENT
Credential:
Phone: 972-588-1000