Provider Demographics
NPI:1679355358
Name:NOVA INTEGRATED CARE LLC
Entity type:Organization
Organization Name:NOVA INTEGRATED CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:715-891-0088
Mailing Address - Street 1:302 W PINE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-9349
Mailing Address - Country:US
Mailing Address - Phone:715-891-0088
Mailing Address - Fax:
Practice Address - Street 1:302 W PINE ST STE 2
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-9349
Practice Address - Country:US
Practice Address - Phone:715-891-0088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center