Healthcare Provider Details

I. General information

NPI: 1497358865
Provider Name (Legal Business Name): INNOVATIVE CHILD & FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3721 W MICHIGAN AVE
LANSING MI
48917-3693
US

IV. Provider business mailing address

3721 W MICHIGAN AVE
LANSING MI
48917-3693
US

V. Phone/Fax

Practice location:
  • Phone: 517-515-6176
  • Fax:
Mailing address:
  • Phone: 517-515-6176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM3000X
TaxonomyMedically Fragile Infants and Children Day Care
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RICARDO DAVID TILLERY
Title or Position: CEO
Credential: LMSW
Phone: 517-703-3387