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General NPI Number Information
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NPI Number | 1225789837
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Entity Type | Organization
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Legal Business Name | INNOVATIVE HEALTH CARE SERVICE OF MIDWEST
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Dates
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Enumeration Date | 01/14/2022
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Last Update Date | 01/14/2022
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Provider Practice Location Address
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Address Line | 4317 176TH ST
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City | COUNTRY CLUB HILLS
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State | IL
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Zip | 60478-4745
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Country | US
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Telephone | 314-305-0738
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Fax | 314-925-2314
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Provider Business Mailing Address
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Address Line | 4317 176TH ST
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City | COUNTRY CLUB HILLS
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State | IL
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Zip | 60478-4745
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Country | US
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Telephone | 314-305-0738
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Fax | 314-925-2314
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DOMINIQUE LAWERENCE
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Credential |
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Telephone | 314-305-0738
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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