Provider Demographics
NPI:1932847902
Name:INNOVATIVE LIFE OF NEW JERSEY
Entity type:Organization
Organization Name:INNOVATIVE LIFE OF NEW JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHINAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-270-4750
Mailing Address - Street 1:8484 GEORGIA AVE STE 900
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-5604
Mailing Address - Country:US
Mailing Address - Phone:202-853-1306
Mailing Address - Fax:
Practice Address - Street 1:2510 HUNTERS GLEN DR
Practice Address - Street 2:
Practice Address - City:PLAINSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08536-3869
Practice Address - Country:US
Practice Address - Phone:301-270-4750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities