Provider Demographics
NPI:1619115391
Name:INNOVATIVE CONSULTING SERVICES
Entity Type:Organization
Organization Name:INNOVATIVE CONSULTING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ARDENA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-467-2778
Mailing Address - Street 1:60 LIGHTWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016
Mailing Address - Country:US
Mailing Address - Phone:678-342-7037
Mailing Address - Fax:678-342-9632
Practice Address - Street 1:60 LIGHTWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016
Practice Address - Country:US
Practice Address - Phone:678-342-7037
Practice Address - Fax:678-342-9632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency