1508157959 NPI number — INNOVATIVE SERVICES INC

Table of content: (NPI 1508157959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508157959 NPI number — INNOVATIVE SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE SERVICES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508157959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7506 STATE ROUTE 5
Provider Second Line Business Mailing Address:
PO BOX 325
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13323-3654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-853-1280
Provider Business Mailing Address Fax Number:
315-853-6087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6700 THOMPSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13211-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-437-1627
Provider Business Practice Location Address Fax Number:
315-437-7931
Provider Enumeration Date:
04/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LOPRESTI
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, COO
Authorized Official Telephone Number:
315-853-1280

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6853 . This is a "MEDICAID PIN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3336650 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01818419 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23530 . This is a "PHARMACY LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0701L004 . This is a "DOH LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: TRM . This is a "MEDICAID ETIN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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