Provider Demographics
NPI:1679289409
Name:INNOBA ABA, INC
Entity type:Organization
Organization Name:INNOBA ABA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKYEONG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:718-819-8828
Mailing Address - Street 1:5143 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5402 217TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE HILLS
Practice Address - State:NY
Practice Address - Zip Code:11364-1429
Practice Address - Country:US
Practice Address - Phone:718-819-8828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management