Provider Demographics
NPI:1316535776
Name:INNOVATIVE WELLNESS CLINIC, INC., A NURSING CORPORATION
Entity Type:Organization
Organization Name:INNOVATIVE WELLNESS CLINIC, INC., A NURSING CORPORATION
Other - Org Name:IWC PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRIMARY CARE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:ALEXIS
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-648-0755
Mailing Address - Street 1:750 OTAY LAKES RD # 111
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10225 AUSTIN DR
Practice Address - Street 2:STE 105
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91978-1521
Practice Address - Country:US
Practice Address - Phone:858-648-0755
Practice Address - Fax:534-429-4287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49264OtherMEDICAL LICENSE
CANP95010963OtherNURSE PRACTITIONER LICENSE NUMBER