Provider Demographics
NPI:1770675712
Name:INNOVO HEALTHCARE, LLC
Entity Type:Organization
Organization Name:INNOVO HEALTHCARE, LLC
Other - Org Name:INTERIM HEALTHCARE OF WESTERN WISCONSIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-377-9617
Mailing Address - Street 1:625 COMMERCE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8278
Mailing Address - Country:US
Mailing Address - Phone:715-377-9617
Mailing Address - Fax:715-377-9623
Practice Address - Street 1:625 COMMERCE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8278
Practice Address - Country:US
Practice Address - Phone:715-377-9617
Practice Address - Fax:715-377-9623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1050251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43113900Medicaid
WI1050OtherSTATE REGULAR HOME HEALTH
WI52-7291Medicare PIN