Provider Demographics
NPI:1518426857
Name:INNOVATIVE TREATMENT ASSOCIATES
Entity Type:Organization
Organization Name:INNOVATIVE TREATMENT ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RULISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-391-9196
Mailing Address - Street 1:3116 CASTLEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:POLLOCK PINES
Mailing Address - State:CA
Mailing Address - Zip Code:95726-9522
Mailing Address - Country:US
Mailing Address - Phone:530-391-9309
Mailing Address - Fax:
Practice Address - Street 1:3581 PALMER DR STE 601
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8238
Practice Address - Country:US
Practice Address - Phone:530-556-5363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-17
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center