Provider Demographics
NPI:1548600174
Name:INNOVATIVE THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:INNOVATIVE THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZACCHEAUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ELEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-237-5456
Mailing Address - Street 1:916 HAY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5314
Mailing Address - Country:US
Mailing Address - Phone:910-237-5456
Mailing Address - Fax:910-848-0492
Practice Address - Street 1:755 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3238
Practice Address - Country:US
Practice Address - Phone:910-237-5456
Practice Address - Fax:910-848-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management