Provider Demographics
NPI:1720353675
Name:INNOVATIVE MEDICAL GROUP
Entity Type:Organization
Organization Name:INNOVATIVE MEDICAL GROUP
Other - Org Name:INNOVATIVE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-570-9773
Mailing Address - Street 1:232 JEREMY DR
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:GA
Mailing Address - Zip Code:30628-1543
Mailing Address - Country:US
Mailing Address - Phone:706-742-9226
Mailing Address - Fax:
Practice Address - Street 1:232 JEREMY DR
Practice Address - Street 2:
Practice Address - City:COLBERT
Practice Address - State:GA
Practice Address - Zip Code:30628-1543
Practice Address - Country:US
Practice Address - Phone:706-742-9226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-11
Last Update Date:2012-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies