Provider Demographics
NPI:1629383906
Name:INNOVATIVE HEALTHCARE
Entity Type:Organization
Organization Name:INNOVATIVE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:203-687-9502
Mailing Address - Street 1:325 BOSTON POST RD.
Mailing Address - Street 2:#1E
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477
Mailing Address - Country:US
Mailing Address - Phone:203-687-9502
Mailing Address - Fax:203-795-5645
Practice Address - Street 1:555 AMITY RD.
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525
Practice Address - Country:US
Practice Address - Phone:203-687-9502
Practice Address - Fax:203-795-5645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT302F00000X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization