Provider Demographics
NPI:1164756755
Name:INNOVATIVE SUPPLY GROUP, LLC
Entity Type:Organization
Organization Name:INNOVATIVE SUPPLY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBOVICS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-363-3001
Mailing Address - Street 1:585 PROSPECT ST
Mailing Address - Street 2:UNIT 304
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5073
Mailing Address - Country:US
Mailing Address - Phone:732-363-3001
Mailing Address - Fax:
Practice Address - Street 1:585 PROSPECT ST
Practice Address - Street 2:UNIT 304
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5073
Practice Address - Country:US
Practice Address - Phone:732-363-3001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1509850332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
6336620001Medicare NSC