Provider Demographics
NPI:1255189023
Name:INNOVATIVE CARE NETWORK
Entity type:Organization
Organization Name:INNOVATIVE CARE NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLERY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, LCSW, SAP, CCS
Authorized Official - Phone:517-515-6176
Mailing Address - Street 1:3721 W MICHIGAN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-3600
Mailing Address - Country:US
Mailing Address - Phone:517-515-6176
Mailing Address - Fax:
Practice Address - Street 1:3721 W MICHIGAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-3600
Practice Address - Country:US
Practice Address - Phone:517-515-6176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVATIVE HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local