Provider Demographics
NPI:1144710658
Name:INNOVIS HEALTH, LLC
Entity type:Organization
Organization Name:INNOVIS HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:GLASNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-364-4554
Mailing Address - Street 1:6501 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3248
Mailing Address - Country:US
Mailing Address - Phone:952-653-2565
Mailing Address - Fax:952-653-2540
Practice Address - Street 1:4110 51ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7776
Practice Address - Country:US
Practice Address - Phone:952-653-2565
Practice Address - Fax:952-653-2540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND13699332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site