Provider Demographics
NPI:1831315084
Name:INNOVATIVE MEDICINE INSTITUTE INC
Entity Type:Organization
Organization Name:INNOVATIVE MEDICINE INSTITUTE INC
Other - Org Name:AJ HEALTH CARE OR NATURAL PAIN RELIEF CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:DUAINE
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-982-9272
Mailing Address - Street 1:PO BOX 6818
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85278-6818
Mailing Address - Country:US
Mailing Address - Phone:480-982-9272
Mailing Address - Fax:480-982-9295
Practice Address - Street 1:2080 W SOUTHERN AVE
Practice Address - Street 2:SUITE B-1
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85220-7455
Practice Address - Country:US
Practice Address - Phone:480-982-9272
Practice Address - Fax:480-982-9295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4153111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT41089Medicare UPIN
AZ66924Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
AZ66926Medicare ID - Type UnspecifiedINDIVIDUAL