Provider Demographics
NPI:1619541596
Name:INTEGRATED INTERVENTION SPECIALISTS, LLC
Entity Type:Organization
Organization Name:INTEGRATED INTERVENTION SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-799-2045
Mailing Address - Street 1:4725 AMBER VALLEY PKWY S STE B
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8614
Mailing Address - Country:US
Mailing Address - Phone:701-478-0221
Mailing Address - Fax:701-478-0222
Practice Address - Street 1:4725 AMBER VALLEY PKWY S STE B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8614
Practice Address - Country:US
Practice Address - Phone:701-478-0221
Practice Address - Fax:701-478-0222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATED INTERVENTION SPECIALISTS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-16
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1479549Medicaid