Provider Demographics
NPI:1437433562
Name:INNOVATIVE SERVICES, INC.
Entity Type:Organization
Organization Name:INNOVATIVE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLONDHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-431-0962
Mailing Address - Street 1:2321 SAN LUIS PL
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5211
Mailing Address - Country:US
Mailing Address - Phone:920-431-0962
Mailing Address - Fax:920-431-7184
Practice Address - Street 1:445 S MADISON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4126
Practice Address - Country:US
Practice Address - Phone:920-431-0962
Practice Address - Fax:920-884-1967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities