MEDICARE: INNOBA, 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	000632	NY

General Provider Information

NPI Number	:	1639561350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOBA, LLC

Provider Business Mailing Address
First Line	:	5143 BELL BLVD
Second Line	:
City	:	BAYSIDE HILLS
State	:	NY
Zip	:	11364-1225
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5143 BELL BLVD
Second Line	:
City	:	BAYSIDE HILLS
State	:	NY
Zip	:	11364-1225
Country	:	US
Telephone Number	:	718-640-6550
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. MIKYEONG KIM
Credential	:	LBA
Telephone Number	:	718-640-6550

Provider Enumeration Date	:	03/04/2015
Last Update Date	:	03/04/2015

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Directions to “INNOBA, LLC ” Practice Location

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