Provider Demographics
NPI:1639561350
Name:INNOBA, LLC
Entity Type:Organization
Organization Name:INNOBA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKYEONG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:LBA
Authorized Official - Phone:718-640-6550
Mailing Address - Street 1:5143 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5143 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE HILLS
Practice Address - State:NY
Practice Address - Zip Code:11364-1225
Practice Address - Country:US
Practice Address - Phone:718-640-6550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000632251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health