Provider Demographics
NPI:1023612264
Name:INNOVAGE PENNSYLVANIA LIFE, LLC
Entity type:Organization
Organization Name:INNOVAGE PENNSYLVANIA LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEZLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-734-9587
Mailing Address - Street 1:8950 E LOWRY BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-7030
Mailing Address - Country:US
Mailing Address - Phone:215-734-9587
Mailing Address - Fax:
Practice Address - Street 1:3232 HENRY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1241
Practice Address - Country:US
Practice Address - Phone:267-774-2920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVAGE PENNSYLVANIA LIFE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101734256-0005Medicaid