Provider Demographics
NPI:1396048542
Name:INNOVATIVE HUMAN RESOURCES-PEE DEE BAND, LLC
Entity type:Organization
Organization Name:INNOVATIVE HUMAN RESOURCES-PEE DEE BAND, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MS ED D
Authorized Official - Phone:404-552-4284
Mailing Address - Street 1:460 SANDYBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-2923
Mailing Address - Country:US
Mailing Address - Phone:404-552-4284
Mailing Address - Fax:
Practice Address - Street 1:460 SANDYBROOKE DR
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-2923
Practice Address - Country:US
Practice Address - Phone:336-886-0142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8001101Y00000X
101YP2500X, 174H00000X, 251E00000X, 251X00000X, 332B00000X, 364S00000X, 376K00000X, 251B00000X
NC0008620494251X00000X
GA731914251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No251X00000XAgenciesSupports BrokerageGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN40918375OtherLICENSE: ACCIDENT, HEALTH, SICKNESS, & LIFE
GA731914OtherINSURANCE: ACCIDENT, SICKNESS, & LIFE LICENSE
NC8620494OtherLICENSE/NPN HEALTH, SICKNESS, ACCIDENT, & LIFE
SC8620494OtherLICENSE/NPN ACCIDENT SICKNESS, HEALTH, & LIFE
GA187956OtherLICENSE PRINCIPAL AGENCY RESIDENT