Provider Demographics
NPI:1184147712
Name:INNOVATIVE MT LLC
Entity type:Organization
Organization Name:INNOVATIVE MT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-706-2804
Mailing Address - Street 1:7395 DESERTSCAPE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-8800
Mailing Address - Country:US
Mailing Address - Phone:702-706-2804
Mailing Address - Fax:
Practice Address - Street 1:7395 DESERTSCAPE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89178-8800
Practice Address - Country:US
Practice Address - Phone:702-706-2804
Practice Address - Fax:512-590-7104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN002484363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty