Provider Demographics
NPI:1336876341
Name:INNOVATIVE MIND SERVICES
Entity Type:Organization
Organization Name:INNOVATIVE MIND SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADEBUKOLA
Authorized Official - Middle Name:REBECCA
Authorized Official - Last Name:ADEBAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-300-9408
Mailing Address - Street 1:27 MYRTLE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3319
Mailing Address - Country:US
Mailing Address - Phone:862-300-9408
Mailing Address - Fax:
Practice Address - Street 1:27 MYRTLE AVE APT 2
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3319
Practice Address - Country:US
Practice Address - Phone:862-300-9408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child