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? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |