Provider Demographics
NPI:1871033167
Name:INNOVATIVE RECOVERY SERVICES LLC
Entity Type:Organization
Organization Name:INNOVATIVE RECOVERY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LADAC, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-915-8367
Mailing Address - Street 1:2051 MARS AVE
Mailing Address - Street 2:APT D5
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-7712
Mailing Address - Country:US
Mailing Address - Phone:575-915-8367
Mailing Address - Fax:
Practice Address - Street 1:2051 MARS AVE
Practice Address - Street 2:APT D5
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-7712
Practice Address - Country:US
Practice Address - Phone:575-915-8367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty