Healthcare Provider Details

I. General information

NPI: 1821723610
Provider Name (Legal Business Name): INNOVIS HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 SHEYENNE ST STE 240
WEST FARGO ND
58078-8546
US

IV. Provider business mailing address

1702 UNIVERSITY DR S ATN: MEDICAL STAFF SERVICES-SSC
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-1530
  • Fax: 701-364-1531
Mailing address:
  • Phone: 701-364-8177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALAN HURLEY
Title or Position: COO
Credential:
Phone: 701-364-7667