Provider Demographics
NPI:1659073120
Name:INNOVA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:INNOVA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-515-3970
Mailing Address - Street 1:669 BOSTON POST RD STE 8
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:669 BOSTON POST RD STE 8
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2739
Practice Address - Country:US
Practice Address - Phone:833-446-6682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVA-SG CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies