Provider Demographics
NPI:1578712717
Name:INNOVATIVE SENIOR CARE
Entity Type:Organization
Organization Name:INNOVATIVE SENIOR CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TEAM LEADER
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTERO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:954-970-2600
Mailing Address - Street 1:3701 W MCNAB RD
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-4966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8241 SW 15TH ST
Practice Address - Street 2:1122
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3271
Practice Address - Country:US
Practice Address - Phone:954-882-8618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 10427252Y00000X, 310400000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTA 10427OtherOTA LICENSE NUMBER