Provider Demographics
NPI:1902643190
Name:INNOVATIVE RESOURCES SSM
Entity type:Organization
Organization Name:INNOVATIVE RESOURCES SSM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:TRAUMA-INFORMED CARE
Authorized Official - Phone:855-311-3335
Mailing Address - Street 1:619 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5110
Mailing Address - Country:US
Mailing Address - Phone:916-891-7552
Mailing Address - Fax:
Practice Address - Street 1:619 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5110
Practice Address - Country:US
Practice Address - Phone:916-891-7552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-13
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty