Provider Demographics
NPI:1174755359
Name:INNOVATIVE HEALTH LLC
Entity type:Organization
Organization Name:INNOVATIVE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:601-968-1690
Mailing Address - Street 1:501 MARSHALL ST STE 605
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1650
Mailing Address - Country:US
Mailing Address - Phone:601-968-1690
Mailing Address - Fax:601-968-1693
Practice Address - Street 1:501 MARSHALL ST STE 605
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1650
Practice Address - Country:US
Practice Address - Phone:601-968-1690
Practice Address - Fax:601-968-1693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06058256Medicaid