Provider Demographics
NPI:1598396905
Name:INNOVATIVE LIFE SOLUTIONS INC
Entity Type:Organization
Organization Name:INNOVATIVE LIFE SOLUTIONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:F
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-270-4750
Mailing Address - Street 1:8484 GEORGIA AVE STE 900
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-5604
Mailing Address - Country:US
Mailing Address - Phone:301-270-4750
Mailing Address - Fax:
Practice Address - Street 1:1703 FRANKFORD ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-6309
Practice Address - Country:US
Practice Address - Phone:301-270-4750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities