Provider Demographics
NPI:1275315632
Name:INNOVATIVE LIFE SOLUTIONS INC
Entity Type:Organization
Organization Name:INNOVATIVE LIFE SOLUTIONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-270-4750
Mailing Address - Street 1:8484 GEORGIA AVE STE 900
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-5604
Mailing Address - Country:US
Mailing Address - Phone:202-853-1306
Mailing Address - Fax:
Practice Address - Street 1:6135 KANSAS AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1505
Practice Address - Country:US
Practice Address - Phone:301-270-4750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC6135Medicaid