Provider Demographics
NPI:1790964625
Name:INNOVATIVE SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:INNOVATIVE SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADRIANE
Authorized Official - Middle Name:BERRY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-856-2293
Mailing Address - Street 1:PO BOX 560416
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28256-0416
Mailing Address - Country:US
Mailing Address - Phone:704-856-2293
Mailing Address - Fax:704-856-2294
Practice Address - Street 1:2730 OLDENWAY DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-9772
Practice Address - Country:US
Practice Address - Phone:704-856-2293
Practice Address - Fax:704-856-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-28
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services