Provider Demographics
NPI:1215149489
Name:INNOVATIVE CONCEPTS
Entity type:Organization
Organization Name:INNOVATIVE CONCEPTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BOONE
Authorized Official - Middle Name:S
Authorized Official - Last Name:KOWALIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-542-4287
Mailing Address - Street 1:15752 OAKHILL COURT
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154
Mailing Address - Country:US
Mailing Address - Phone:734-542-4287
Mailing Address - Fax:734-542-4289
Practice Address - Street 1:15752 OAKHILL COURT
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154
Practice Address - Country:US
Practice Address - Phone:734-542-4287
Practice Address - Fax:734-542-4289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0323939Medicaid
MI4431900Medicaid