Provider Demographics
NPI:1508077157
Name:INNOVATIVE HEALTH CARE CONCEPTS, INC
Entity Type:Organization
Organization Name:INNOVATIVE HEALTH CARE CONCEPTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:208-529-8526
Mailing Address - Street 1:790 S HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4749
Mailing Address - Country:US
Mailing Address - Phone:208-529-8526
Mailing Address - Fax:208-529-8597
Practice Address - Street 1:790 S HOLMES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4749
Practice Address - Country:US
Practice Address - Phone:208-529-8526
Practice Address - Fax:208-529-8597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002742000Medicaid