MEDICARE: INNOVATIVE LIFE OF MARYLAND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1043072853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE LIFE OF MARYLAND

Provider Business Mailing Address
First Line	:	8484 GEORGIA AVE STE 900
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-5604
Country	:	US
Telephone Number	:	301-270-4750
Fax Number	:

Provider Business Practice Location Address
First Line	:	8484 GEORGIA AVE STE 900
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-5604
Country	:	US
Telephone Number	:	301-270-4750
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF PROGRAM SUPPORTS
Name	:	MRS. SHERRY KING
Credential	:
Telephone Number	:	301-270-4750

Provider Enumeration Date	:	01/26/2024
Last Update Date	:	01/26/2024

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