Basic Information
| Provider Information | |||||||||
| NPI: | 1114230893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVATIVE HEALTH CARE OF HAVASU LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 297 LAKE HAVASU AVE SOUTH | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288547666 | ||||||||
| FaxNumber: | 9288547660 | ||||||||
| Practice Location | |||||||||
| Address1: | 297 LAKE HAVASU AVE SOUTH | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288547666 | ||||||||
| FaxNumber: | 9288547660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2010 | ||||||||
| LastUpdateDate: | 05/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | TILGNER | ||||||||
| AuthorizedOfficialFirstName: | SUMMER | ||||||||
| AuthorizedOfficialMiddleName: | YVONNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9288547666 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | DNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | AP3726 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
No ID Information.