1902330285 NPI number — INNOVATIVE PAIN MANAGEMENT MEDICAL GROUP

Table of content: (NPI 1902330285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902330285 NPI number — INNOVATIVE PAIN MANAGEMENT MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE PAIN MANAGEMENT MEDICAL GROUP
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:
1902330285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 W HARBOR DR
Provider Second Line Business Mailing Address:
SUITE 126
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92101-7709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-434-4019
Provider Business Mailing Address Fax Number:
619-434-4023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 EUCLID AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
NATIONAL CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91950-2951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-434-4019
Provider Business Practice Location Address Fax Number:
619-434-4023
Provider Enumeration Date:
04/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WYNN
Authorized Official First Name:
BRENTON
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
619-434-4019

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  A73257 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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