Provider Demographics
NPI:1366993263
Name:INNOVATIVE PRIMARY CARE, LLC
Entity type:Organization
Organization Name:INNOVATIVE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:PINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-200-8672
Mailing Address - Street 1:7035 MIDDLEBROOK PIKE STE B
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1387
Mailing Address - Country:US
Mailing Address - Phone:865-200-8672
Mailing Address - Fax:865-544-1570
Practice Address - Street 1:7035 MIDDLEBROOK PIKE STE B
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1387
Practice Address - Country:US
Practice Address - Phone:865-200-8672
Practice Address - Fax:865-544-1570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ003416Medicaid