Healthcare Provider Details

I. General information

NPI: 1144710658
Provider Name (Legal Business Name): INNOVIS HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 51ST AVE S
FARGO ND
58104-7776
US

IV. Provider business mailing address

6501 CITY WEST PKWY
EDEN PRAIRIE MN
55344-3248
US

V. Phone/Fax

Practice location:
  • Phone: 952-653-2565
  • Fax: 952-653-2540
Mailing address:
  • Phone: 952-653-2565
  • Fax: 952-653-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number13699
License Number StateND

VIII. Authorized Official

Name: GREGORY C GLASNER
Title or Position: MD
Credential: MD
Phone: 701-364-4554