Provider Demographics
NPI:1306114566
Name:INNOVATIVE CARE CENTER
Entity type:Organization
Organization Name:INNOVATIVE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-488-1036
Mailing Address - Street 1:20 PROSPECT AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1997
Mailing Address - Country:US
Mailing Address - Phone:201-488-1036
Mailing Address - Fax:201-489-6966
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1997
Practice Address - Country:US
Practice Address - Phone:201-488-1036
Practice Address - Fax:201-489-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center