Healthcare Provider Details

I. General information

NPI: 1639993983
Provider Name (Legal Business Name): INNOVATIVE HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N6366 LAMPHERE RD
ARKANSAW WI
54721-9412
US

IV. Provider business mailing address

N6366 LAMPHERE RD
ARKANSAW WI
54721-9412
US

V. Phone/Fax

Practice location:
  • Phone: 715-495-0898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: GWEN SWEENEY
Title or Position: MANAGING MEMBER
Credential:
Phone: 715-495-0898