Healthcare Provider Details

I. General information

NPI: 1619206703
Provider Name (Legal Business Name): INNOVATIVE SENIOR REHABILITATION SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 11/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W PINE ST
LODI CA
95240-2020
US

IV. Provider business mailing address

222 W PINE ST
LODI CA
95240-2020
US

V. Phone/Fax

Practice location:
  • Phone: 209-368-1009
  • Fax: 209-368-1024
Mailing address:
  • Phone: 209-368-1009
  • Fax: 209-368-1024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH HADLEY
Title or Position: VP CFO
Credential:
Phone: 916-690-0757