Provider Demographics
NPI:1700270212
Name:INNOVATIVE COMMUNITY ACCESS INC
Entity Type:Organization
Organization Name:INNOVATIVE COMMUNITY ACCESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ARDIZONE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:201-486-9500
Mailing Address - Street 1:272 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-2515
Mailing Address - Country:US
Mailing Address - Phone:201-486-9500
Mailing Address - Fax:
Practice Address - Street 1:272 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-2515
Practice Address - Country:US
Practice Address - Phone:201-486-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health