Provider Demographics
NPI:1598827495
Name:INNOVATIVE SENIOR REHABILITATION SERVICES INC.
Entity Type:Organization
Organization Name:INNOVATIVE SENIOR REHABILITATION SERVICES INC.
Other - Org Name:INNOVATIVE SENIOR REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:HADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-690-0757
Mailing Address - Street 1:222 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-2020
Mailing Address - Country:US
Mailing Address - Phone:209-368-1009
Mailing Address - Fax:209-368-1024
Practice Address - Street 1:2220 W KETTLEMAN LN
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4347
Practice Address - Country:US
Practice Address - Phone:209-365-6764
Practice Address - Fax:209-365-6764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2011-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACH1035OtherRAILROAD MEDICARE PTAN
CAZZZ17913ZMedicare UPIN