# INNOVATIVE PROFESSIONAL SERVICE LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1679836910
- **Authorized official:** MR. TERRY YEITER (OFFICE MANAGER)
- **Authorized official phone:** (260) 432-6508

## Contact information

- **Practice address:** 3464 STELLHORN RD, FORT WAYNE, IN 46815-4630
- **Practice address phone:** (260) 432-6508
- **Practice address fax:** (260) 432-6586
- **Mailing address:** 3464 STELLHORN RD, FORT WAYNE, IN 46815-4630
- **Mailing address phone:** (260) 432-6508
- **Mailing address fax:** (260) 432-6586

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | 01025672 | IN | Yes |

## Other

- **Enumeration date:** 06/21/2012
- **Last updated:** 06/21/2012