Provider Demographics
NPI:1447522396
Name:INNOVATIVE CLINICAL SERVICES
Entity type:Organization
Organization Name:INNOVATIVE CLINICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SEANLONDA
Authorized Official - Middle Name:N
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-826-6435
Mailing Address - Street 1:160 KYNDAL DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-4862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 KYNDAL DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-4862
Practice Address - Country:US
Practice Address - Phone:678-826-6435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health