MEDICARE: INNOVATIVE CARE AND CONSULTING, LLC

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	363LA2200X	Adult Health Nurse Practitioner

General Provider Information

NPI Number	:	1508332297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE CARE AND CONSULTING, LLC

Provider Business Mailing Address
First Line	:	2 RUNNING BROOK DRIVE
Second Line	:	2 RUNNING BROOK DRIVE
City	:	LANCASTER
State	:	NY
Zip	:	14086
Country	:	US
Telephone Number	:	716-864-6316
Fax Number	:

Provider Business Practice Location Address
First Line	:	3024 NIAGARA FALLS BLVD STE 116
Second Line	:
City	:	NORTH TONAWANDA
State	:	NY
Zip	:	14120-1116
Country	:	US
Telephone Number	:	716-217-4321
Fax Number	:	716-219-2469

Authorized Official
Title or Position	:	OWNER
Name	:	LISA M DAVIS WHEELER
Credential	:	NP
Telephone Number	:	716-217-4321

Provider Enumeration Date	:	10/19/2018
Last Update Date	:	01/18/2021

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