Provider Demographics
NPI:1114230893
Name:INNOVATIVE HEALTH CARE OF HAVASU LLC
Entity Type:Organization
Organization Name:INNOVATIVE HEALTH CARE OF HAVASU LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:TILGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:928-854-7666
Mailing Address - Street 1:297 LAKE HAVASU AVE SOUTH
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403
Mailing Address - Country:US
Mailing Address - Phone:928-854-7666
Mailing Address - Fax:928-854-7660
Practice Address - Street 1:297 LAKE HAVASU AVE SOUTH
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-854-7666
Practice Address - Fax:928-854-7660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3726364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty