Provider Demographics
NPI:1356651533
Name:INNOVATION LIFE CARE, LLC
Entity Type:Organization
Organization Name:INNOVATION LIFE CARE, LLC
Other - Org Name:BRIGHTSTAR OF WILKES BARRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCARANTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-362-8725
Mailing Address - Street 1:561 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-2203
Mailing Address - Country:US
Mailing Address - Phone:570-602-1560
Mailing Address - Fax:570-602-1569
Practice Address - Street 1:561 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-2203
Practice Address - Country:US
Practice Address - Phone:570-602-1560
Practice Address - Fax:570-602-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA20053601251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health