Provider Demographics
NPI:1730621756
Name:INNOVATIVE SOLUTIONS PERSONAL CARE HOME
Entity type:Organization
Organization Name:INNOVATIVE SOLUTIONS PERSONAL CARE HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TENESHA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:GIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:229-462-2055
Mailing Address - Street 1:569 PHYLLIS CIR
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-6438
Mailing Address - Country:US
Mailing Address - Phone:229-462-2055
Mailing Address - Fax:
Practice Address - Street 1:569 PHYLLIS CIR
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-6438
Practice Address - Country:US
Practice Address - Phone:229-462-2055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities