Provider Demographics
NPI:1225882483
Name:INNOVATION HEALTH SYSTEM, LLC
Entity Type:Organization
Organization Name:INNOVATION HEALTH SYSTEM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ASAH
Authorized Official - Last Name:NKWETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-519-7277
Mailing Address - Street 1:2138 ESPEY CT STE 1
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2495
Mailing Address - Country:US
Mailing Address - Phone:443-519-7277
Mailing Address - Fax:443-470-7718
Practice Address - Street 1:2138 ESPEY CT STE 1
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2495
Practice Address - Country:US
Practice Address - Phone:443-519-7277
Practice Address - Fax:443-470-7718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health