MEDICARE: NOVA INTEGRATED CARE 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1679355358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA INTEGRATED CARE LLC

Provider Business Mailing Address
First Line	:	302 W PINE ST STE 2
Second Line	:
City	:	EAGLE RIVER
State	:	WI
Zip	:	54521-9349
Country	:	US
Telephone Number	:	715-891-0088
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 W PINE ST STE 2
Second Line	:
City	:	EAGLE RIVER
State	:	WI
Zip	:	54521-9349
Country	:	US
Telephone Number	:	715-891-0088
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICIAN ASSISTANT
Name	:	JILL BRUNSTAD
Credential	:	PA
Telephone Number	:	715-891-0088

Provider Enumeration Date	:	10/18/2023
Last Update Date	:	10/18/2023

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