Provider Demographics
NPI:1821494014
Name:INNOVATIVE MEDICINE
Entity Type:Organization
Organization Name:INNOVATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TSZ
Authorized Official - Middle Name:YING
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-415-1990
Mailing Address - Street 1:811 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-2606
Mailing Address - Country:US
Mailing Address - Phone:213-415-1990
Mailing Address - Fax:213-415-1940
Practice Address - Street 1:811 WILSHIRE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2606
Practice Address - Country:US
Practice Address - Phone:213-415-1990
Practice Address - Fax:213-415-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99205207R00000X
CAPT40619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty