Healthcare Provider Details

I. General information

NPI: 1427791607
Provider Name (Legal Business Name): INNOVATE RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14718 KESWICK ST
VAN NUYS CA
91405-1205
US

IV. Provider business mailing address

14718 KESWICK ST
VAN NUYS CA
91405-1205
US

V. Phone/Fax

Practice location:
  • Phone: 181-852-3002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ANA KESARYAN
Title or Position: CEO
Credential:
Phone: 818-523-0025