Provider Demographics
NPI:1316009202
Name:INNOVATIVE SENIOR REHABILITATION SERVICES, INC.
Entity Type:Organization
Organization Name:INNOVATIVE SENIOR REHABILITATION SERVICES, INC.
Other - Org Name:INNOVATIVE SENIOR REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:HADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:916-690-0757
Mailing Address - Street 1:222 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-2020
Mailing Address - Country:US
Mailing Address - Phone:209-368-1009
Mailing Address - Fax:209-368-1024
Practice Address - Street 1:9325 E STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1282
Practice Address - Country:US
Practice Address - Phone:916-685-4550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2010-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ17913ZMedicare PIN