Healthcare Provider Details

I. General information

NPI: 1528511912
Provider Name (Legal Business Name): INNOVATIVE TEAM CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 CARRIAGE CROSSING LN
MIDDLETOWN CT
06457-5827
US

IV. Provider business mailing address

14 CARRIAGE CROSSING LN
MIDDLETOWN CT
06457-5827
US

V. Phone/Fax

Practice location:
  • Phone: 860-834-3601
  • Fax:
Mailing address:
  • Phone: 860-834-3601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JAMES C ADU
Title or Position: OWNER
Credential:
Phone: 860-834-3601