Provider Demographics
NPI:1528214913
Name:INNOVATIVE MOBILE SERVICES LLC
Entity Type:Organization
Organization Name:INNOVATIVE MOBILE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-626-9729
Mailing Address - Street 1:PO BOX 2966
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2966
Mailing Address - Country:US
Mailing Address - Phone:417-626-9729
Mailing Address - Fax:
Practice Address - Street 1:202 MILLER WAY
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-8336
Practice Address - Country:US
Practice Address - Phone:417-434-4935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18723335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1528214913Medicaid
KS200251380AMedicaid
KS130574Medicare PIN
MOMA1786Medicare PIN
KS200251380AMedicaid