Healthcare Provider Details

I. General information

NPI: 1902004476
Provider Name (Legal Business Name): INNOVATIVE LIVING INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 EXTON CMNS
EXTON PA
19341-2453
US

IV. Provider business mailing address

585 EXTON CMNS
EXTON PA
19341-2453
US

V. Phone/Fax

Practice location:
  • Phone: 610-280-0610
  • Fax: 610-280-0618
Mailing address:
  • Phone: 610-280-0610
  • Fax: 610-280-0618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. WOLANYO K AGUDU
Title or Position: OWNER
Credential:
Phone: 610-280-0610