Provider Demographics
NPI:1225789837
Name:INNOVATIVE HEALTH CARE SERVICE OF MIDWEST
Entity Type:Organization
Organization Name:INNOVATIVE HEALTH CARE SERVICE OF MIDWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWERENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-305-0738
Mailing Address - Street 1:4317 176TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4745
Mailing Address - Country:US
Mailing Address - Phone:314-305-0738
Mailing Address - Fax:314-925-2314
Practice Address - Street 1:4317 176TH ST
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-4745
Practice Address - Country:US
Practice Address - Phone:314-305-0738
Practice Address - Fax:314-925-2314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health