Provider Demographics
NPI:1356931513
Name:INNOVATIVE ADDICTION SERVICES
Entity type:Organization
Organization Name:INNOVATIVE ADDICTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:TILLERY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, LMSW, CAADC
Authorized Official - Phone:517-703-3387
Mailing Address - Street 1:3721 W MICHIGAN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-3600
Mailing Address - Country:US
Mailing Address - Phone:517-515-6176
Mailing Address - Fax:
Practice Address - Street 1:3721 W MICHIGAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-3600
Practice Address - Country:US
Practice Address - Phone:517-515-6176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVATIVE HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children