Provider Demographics
NPI:1558123471
Name:INNOVATIVE NETWORK GROUP
Entity Type:Organization
Organization Name:INNOVATIVE NETWORK GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PRINCIPAL
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUYENAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MS,MT
Authorized Official - Phone:310-462-0621
Mailing Address - Street 1:13200 CROSSROADS PKWY N STE 315
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91746-3420
Mailing Address - Country:US
Mailing Address - Phone:310-462-0621
Mailing Address - Fax:
Practice Address - Street 1:13200 CROSSROADS PKWY N STE 315
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91746-3420
Practice Address - Country:US
Practice Address - Phone:310-462-0621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center