Provider Demographics
NPI:1871176826
Name:INNOVATIVE LIFE OF NEW JERSEY
Entity type:Organization
Organization Name:INNOVATIVE LIFE OF NEW JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHINAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-270-4750
Mailing Address - Street 1:1900 MOUNT HOLLY RD STE 600A
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-4722
Mailing Address - Country:US
Mailing Address - Phone:609-526-3900
Mailing Address - Fax:301-264-1154
Practice Address - Street 1:158A EATONCREST DR
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1261
Practice Address - Country:US
Practice Address - Phone:609-526-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0726524Medicaid