Provider Demographics
NPI:1942866017
Name:INNOVATIVE FAMILY HEALTH PRACTICES LLC
Entity Type:Organization
Organization Name:INNOVATIVE FAMILY HEALTH PRACTICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-892-7000
Mailing Address - Street 1:4135 S POWER RD STE 120
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-3626
Mailing Address - Country:US
Mailing Address - Phone:480-892-7000
Mailing Address - Fax:480-545-7001
Practice Address - Street 1:4135 S POWER RD STE 120
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-3626
Practice Address - Country:US
Practice Address - Phone:480-892-7000
Practice Address - Fax:480-545-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty