MEDICARE: INNOBA ABA, INC

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	251B00000X	Case Management Agency
2	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1679289409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOBA ABA, INC

Provider Business Mailing Address
First Line	:	5143 BELL BLVD
Second Line	:
City	:	BAYSIDE HILLS
State	:	NY
Zip	:	11364-1225
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5402 217TH ST
Second Line	:
City	:	BAYSIDE HILLS
State	:	NY
Zip	:	11364-1429
Country	:	US
Telephone Number	:	718-819-8828
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. MIKYEONG KIM
Credential	:	ED.D
Telephone Number	:	718-819-8828

Provider Enumeration Date	:	01/25/2023
Last Update Date	:	01/25/2023

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