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General NPI Number Information
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NPI Number | 1871176826
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Entity Type | Organization
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Legal Business Name | INNOVATIVE LIFE OF NEW JERSEY
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Dates
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Enumeration Date | 04/28/2021
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Last Update Date | 04/28/2021
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Provider Practice Location Address
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Address Line | 158A EATONCREST DR
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City | EATONTOWN
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State | NJ
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Zip | 07724-1261
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Country | US
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Telephone | 609-526-3900
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Fax |
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Provider Business Mailing Address
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Address Line | 1900 MOUNT HOLLY RD STE 600A
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City | BURLINGTON
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State | NJ
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Zip | 08016-4722
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Country | US
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Telephone | 609-526-3900
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Fax | 301-264-1154
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | SHINAVIA MCKINNEY
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Credential |
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Telephone | 301-270-4750
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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