Basic Information
| Provider Information | |||||||||
| NPI: | 1619541596 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED INTERVENTION SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4725 AMBER VALLEY PKWY S STE B | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581048614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014780221 | ||||||||
| FaxNumber: | 7014780222 | ||||||||
| Practice Location | |||||||||
| Address1: | 4725 AMBER VALLEY PKWY S STE B | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581048614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014780221 | ||||||||
| FaxNumber: | 7014780222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2021 | ||||||||
| LastUpdateDate: | 05/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | HAMAN | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7017992045 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTEGRATED INTERVENTION SPECIALISTS, LLC | ||||||||
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| NPICertificationDate: | 05/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1479549 | 05 | ND | MEDICAID |