Provider Demographics
NPI:1003146143
Name:INNOVATIVE MEDICAL, INC.
Entity Type:Organization
Organization Name:INNOVATIVE MEDICAL, INC.
Other - Org Name:NOVO TOTAL WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:JEON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, MPH
Authorized Official - Phone:770-988-2779
Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 2203
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4539
Mailing Address - Country:US
Mailing Address - Phone:770-988-2779
Mailing Address - Fax:678-730-0229
Practice Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 2203
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4539
Practice Address - Country:US
Practice Address - Phone:770-988-2779
Practice Address - Fax:678-730-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty