Healthcare Provider Details

I. General information

NPI: 1780140798
Provider Name (Legal Business Name): INNOVATIVE CARE NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CAPCOM AVE STE 102C
WAKE FOREST NC
27587-6537
US

IV. Provider business mailing address

120 CAPCOM AVE STE 102C
WAKE FOREST NC
27587-6537
US

V. Phone/Fax

Practice location:
  • Phone: 215-279-1509
  • Fax:
Mailing address:
  • Phone: 215-279-1509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: KIANNA L CHAPMAN
Title or Position: CEO/OWNER
Credential:
Phone: 215-279-1509