Healthcare Provider Details

I. General information

NPI: 1386851442
Provider Name (Legal Business Name): INNOVATIVE WORK SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 WEST 39TH STREET ROOM 201
SHADYSIDE OH
43947
US

IV. Provider business mailing address

24 WEST 39TH STREET ROOM 201
SHADYSIDE OH
43947
US

V. Phone/Fax

Practice location:
  • Phone: 740-671-3188
  • Fax: 740-671-3187
Mailing address:
  • Phone: 740-671-3188
  • Fax: 740-671-3187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0800577
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0800577
License Number StateOH

VIII. Authorized Official

Name: MR. MARK STEPHEN BASICH
Title or Position: PRESIDENT
Credential: P.T.
Phone: 740-671-3188