Provider Demographics
NPI:1306949896
Name:INNOVATIVE PSYCHIATRIC CARE PC
Entity type:Organization
Organization Name:INNOVATIVE PSYCHIATRIC CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-279-6200
Mailing Address - Street 1:3900 INGERSOLL AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-3534
Mailing Address - Country:US
Mailing Address - Phone:515-279-6200
Mailing Address - Fax:515-279-4528
Practice Address - Street 1:3900 INGERSOLL AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-3534
Practice Address - Country:US
Practice Address - Phone:515-279-6200
Practice Address - Fax:515-279-4528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0249649Medicaid
IAI3968Medicare PIN