MEDICARE: INNOVATIVE HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1437859782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE HEALTH

Provider Business Mailing Address
First Line	:	PO BOX 1256
Second Line	:
City	:	WATFORD CITY
State	:	ND
Zip	:	58854-1256
Country	:	US
Telephone Number	:	701-444-2888
Fax Number	:	701-444-2813

Provider Business Practice Location Address
First Line	:	340 N MAIN ST STE 311
Second Line	:
City	:	WATFORD CITY
State	:	ND
Zip	:	58854-7308
Country	:	US
Telephone Number	:	701-444-2888
Fax Number	:	701-444-2813

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	LISA MARIE SANFORD
Credential	:	FNP
Telephone Number	:	701-444-2888

Provider Enumeration Date	:	03/06/2023
Last Update Date	:	03/06/2023

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