MEDICARE: INNOVATIVE ENRICHMENT SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1538678669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE ENRICHMENT SERVICES, LLC

Provider Business Mailing Address
First Line	:	1609 VENETIAN WAY
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23322-6998
Country	:	US
Telephone Number	:	757-576-5592
Fax Number	:

Provider Business Practice Location Address
First Line	:	1932 KEMPSVILLE RD STE 106
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6953
Country	:	US
Telephone Number	:	757-576-5592
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. TEISHA GRANT-STILL
Credential	:
Telephone Number	:	757-576-5592

Provider Enumeration Date	:	09/20/2017
Last Update Date	:	09/08/2021

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