Healthcare Provider Details

I. General information

NPI: 1831547397
Provider Name (Legal Business Name): INNOVATION ALLIANCE IPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E ENTERPRISE AVE SUITE 101
APPLETON WI
54913-7862
US

IV. Provider business mailing address

691 S GREEN BAY RD # 168
NEENAH WI
54956-3153
US

V. Phone/Fax

Practice location:
  • Phone: 920-560-1100
  • Fax: 920-560-1112
Mailing address:
  • Phone: 920-209-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. CURT KUBIAK
Title or Position: CEO
Credential:
Phone: 920-560-1001