Provider Demographics
NPI:1861255333
Name:INNOVATION HEALTH SYSTEM, LLC
Entity type:Organization
Organization Name:INNOVATION HEALTH SYSTEM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ASAH
Authorized Official - Last Name:NKWETTA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP-BC
Authorized Official - Phone:443-470-7916
Mailing Address - Street 1:2138 ESPEY CT STE 1
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2495
Mailing Address - Country:US
Mailing Address - Phone:443-470-7916
Mailing Address - Fax:443-470-7718
Practice Address - Street 1:2138 ESPEY CT STE 1
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2495
Practice Address - Country:US
Practice Address - Phone:443-470-7916
Practice Address - Fax:443-470-7718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-06
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty