Provider Demographics
NPI:1821234030
Name:INNOVATIVE MEDICINE P.C.
Entity Type:Organization
Organization Name:INNOVATIVE MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:STRUBLE
Authorized Official - Last Name:SOURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-740-1265
Mailing Address - Street 1:318 TOWN CENTER DR.
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-740-1265
Mailing Address - Fax:248-740-1265
Practice Address - Street 1:318 TOWN CENTER DR.
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-740-1265
Practice Address - Fax:248-740-1265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty