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General NPI Number Information
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NPI Number | 1740932227
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Entity Type | Organization
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Legal Business Name | INNOVATIVE CLINICAL SERVICES LLC
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Dates
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Enumeration Date | 01/25/2022
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Last Update Date | 02/18/2022
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Provider Practice Location Address
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Address Line | 4439 COUNTRY CLUB RD
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City | STATESBORO
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State | GA
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Zip | 30458-9188
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Country | US
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Telephone | 912-489-7979
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Fax |
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Provider Business Mailing Address
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Address Line | 4439 COUNTRY CLUB RD
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City | STATESBORO
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State | GA
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Zip | 30458-9188
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Country | US
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Telephone | 912-489-7979
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Fax |
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Authorized Official
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Title or Position | OWNER/AUTHORIZED OFFICIAL
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Name | BENJAMIN ROSS
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Credential | PHARMD
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Telephone | 912-531-0095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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