| Organization Name: | INNOVATIVE PROFESSIONAL SERVICE LLC |
| NPI Number: | 1679836910 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TERRY YEITER (OFFICE MANAGER) |
| Mailing Address: | 3464 Stellhorn Rd Fort Wayne |
| State: | IN US |
| Postal Code: | 468154630 |
| Phone Number: | 2604326508 |
| Fax Number: | 2604326586 |
| NPI Enumeration Date: | 06/21/2012 |
| NPI Last Update Date: | 06/21/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 01025672 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |