Provider Demographics
NPI:1538678669
Name:INNOVATIVE ENRICHMENT SERVICES, LLC
Entity Type:Organization
Organization Name:INNOVATIVE ENRICHMENT SERVICES, LLC
Other - Org Name:INNOVATIVE ENRICHMENT SERVICES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT-STILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-576-5592
Mailing Address - Street 1:1609 VENETIAN WAY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-6998
Mailing Address - Country:US
Mailing Address - Phone:757-576-5592
Mailing Address - Fax:
Practice Address - Street 1:1932 KEMPSVILLE RD STE 106
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-6953
Practice Address - Country:US
Practice Address - Phone:757-576-5592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health