1518426857 NPI number — INNOVATIVE TREATMENT ASSOCIATES

Table of content: (NPI 1518426857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518426857 NPI number — INNOVATIVE TREATMENT ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE TREATMENT ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518426857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3116 CASTLEWOOD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POLLOCK PINES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95726-9522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-391-9309
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3581 PALMER DR STE 601
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMERON PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95682-8238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-556-5363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
RULISON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
530-391-9196

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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