1700913209 NPI number — INNOVATIVE LIFE SOLUTIONS, INC

Table of content: (NPI 1700913209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700913209 NPI number — INNOVATIVE LIFE SOLUTIONS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE LIFE SOLUTIONS, 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:
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:
1700913209
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6475 NEW HAMPSHIRE AVE
Provider Second Line Business Mailing Address:
SUITE 760
Provider Business Mailing Address City Name:
HYATTSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20783-3269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-270-4750
Provider Business Mailing Address Fax Number:
301-270-4754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7416 BLAIR RD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20012-1820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-270-4750
Provider Business Practice Location Address Fax Number:
301-270-4754
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CARRINGTON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
301-270-4750

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  HFD03-0206 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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