Provider Demographics
NPI:1619796208
Name:INNOVATIVE SUPPORT SERVICES
Entity type:Organization
Organization Name:INNOVATIVE SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-852-0655
Mailing Address - Street 1:PO BOX 544
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:VA
Mailing Address - Zip Code:24127-0544
Mailing Address - Country:US
Mailing Address - Phone:804-852-0655
Mailing Address - Fax:
Practice Address - Street 1:1101 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6413
Practice Address - Country:US
Practice Address - Phone:804-852-0655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services