Provider Demographics
NPI:1881369510
Name:INNOVATIVE MEDICINE LLC
Entity type:Organization
Organization Name:INNOVATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BEESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-449-0565
Mailing Address - Street 1:850 E 9400 S STE 101
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-4114
Mailing Address - Country:US
Mailing Address - Phone:385-449-0565
Mailing Address - Fax:
Practice Address - Street 1:850 E 9400 S STE 101
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4114
Practice Address - Country:US
Practice Address - Phone:385-449-0565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty