Provider Demographics
NPI:1003407735
Name:INNOVATIVE MEDICAL GROUP
Entity Type:Organization
Organization Name:INNOVATIVE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:725-710-9159
Mailing Address - Street 1:44045 MARGARITA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-2729
Mailing Address - Country:US
Mailing Address - Phone:951-517-7916
Mailing Address - Fax:
Practice Address - Street 1:4500 BROCKTON AVE STE 305
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4027
Practice Address - Country:US
Practice Address - Phone:206-445-9978
Practice Address - Fax:858-280-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-26
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty