Healthcare Provider Details

I. General information

NPI: 1881369510
Provider Name (Legal Business Name): INNOVATIVE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E 9400 S STE 101
SANDY UT
84094-4114
US

IV. Provider business mailing address

850 E 9400 S STE 101
SANDY UT
84094-4114
US

V. Phone/Fax

Practice location:
  • Phone: 385-449-0565
  • Fax:
Mailing address:
  • Phone: 385-449-0565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM BEESLEY
Title or Position: PARTNER
Credential:
Phone: 385-449-0565