Basic Information
| Provider Information | |||||||||
| NPI: | 1114361177 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INNOVIS HEALTH LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ESSENTIA HEALTH CASSELTON CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1450 NW7813 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554857813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 9TH AVE N | ||||||||
| Address2: | |||||||||
| City: | CASSELTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580123339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013474445 | ||||||||
| FaxNumber: | 7013475276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2013 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HURLEY | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7013647667 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ESSENTIA HEALTH MBR | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14510 | 05 | ND | MEDICAID |