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General NPI Number Information
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NPI Number | 1467056655
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Entity Type | Organization
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Legal Business Name | INNOVAGE PENNSYLVANIA LIFE, LLC
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Dates
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Enumeration Date | 11/28/2020
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Last Update Date | 11/28/2020
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Provider Practice Location Address
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Address Line | 5364 JACKSON ST
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City | PHILADELPHIA
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State | PA
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Zip | 19124-1565
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Country | US
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Telephone | 215-288-3303
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Fax |
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Provider Business Mailing Address
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Address Line | 8950 E LOWRY BLVD
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City | DENVER
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State | CO
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Zip | 80230-7030
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Country | US
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Telephone | 215-734-9587
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | LEZLIE CORBIN
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Credential |
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Telephone | 215-734-9587
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251T00000X
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Taxonomy Name | PACE Provider Organization
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License Number |
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License Number State |
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