Provider Demographics
NPI:1861864456
Name:INNOVATION HEALTHCARE SYSTEMS LLC
Entity Type:Organization
Organization Name:INNOVATION HEALTHCARE SYSTEMS LLC
Other - Org Name:VERSAMED MEDICAL WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-778-0077
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-0147
Mailing Address - Country:US
Mailing Address - Phone:706-778-0077
Mailing Address - Fax:
Practice Address - Street 1:11680 GREAT OAKS WAY
Practice Address - Street 2:SUITE 150
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-2457
Practice Address - Country:US
Practice Address - Phone:706-778-0077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008431111N00000X
GA003705207Q00000X
GARN202988363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty