Provider Demographics
NPI:1164658597
Name:INNOVATIVE COMPLIANCE SOLUTIONS
Entity Type:Organization
Organization Name:INNOVATIVE COMPLIANCE SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DESARETA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-609-5288
Mailing Address - Street 1:PO BOX 38514
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-1009
Mailing Address - Country:US
Mailing Address - Phone:704-609-5288
Mailing Address - Fax:704-874-1803
Practice Address - Street 1:4912 DUNCAN LN
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-9361
Practice Address - Country:US
Practice Address - Phone:704-874-1813
Practice Address - Fax:704-874-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC036-269320800000X
322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604404Medicaid