Provider Demographics
NPI:1669437349
Name:INNOVATIVE PRIMARY CARE LLC
Entity type:Organization
Organization Name:INNOVATIVE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-776-0626
Mailing Address - Street 1:2915 E BASELINE RD
Mailing Address - Street 2:#101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2425
Mailing Address - Country:US
Mailing Address - Phone:480-776-0626
Mailing Address - Fax:480-776-0627
Practice Address - Street 1:2915 E BASELINE RD
Practice Address - Street 2:#101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2425
Practice Address - Country:US
Practice Address - Phone:480-776-0626
Practice Address - Fax:480-776-0627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23910173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ104263Medicare PIN