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General NPI Number Information
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NPI Number | 1962710343
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Entity Type | Organization
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Legal Business Name | INNOVATIVE MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 09/20/2010
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Last Update Date | 09/20/2010
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Provider Practice Location Address
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Address Line | 10105 QUAKER RIDGE CT
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City | FISHERS
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State | IN
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Zip | 46037-9484
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Country | US
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Telephone | 317-407-6275
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Fax | 317-576-8147
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Provider Business Mailing Address
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Address Line | 10105 QUAKER RIDGE CT
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City | FISHERS
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State | IN
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Zip | 46037-9484
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Country | US
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Telephone | 317-407-6275
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Fax | 317-576-8147
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Authorized Official
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Title or Position | CO-OWNER
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Name | MR. MARK DALE
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Credential |
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Telephone | 317-407-6275
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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