Provider Demographics
NPI:1629659016
Name:INNOVA PHYSICIAN NETWORK
Entity Type:Organization
Organization Name:INNOVA PHYSICIAN NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NETWORK DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:JOON
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-639-6593
Mailing Address - Street 1:1403 N. FAIR OAKS AVENUE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 N. FAIR OAKS AVENUE
Practice Address - Street 2:SUITE 3
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103
Practice Address - Country:US
Practice Address - Phone:323-639-6593
Practice Address - Fax:626-398-0357
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVA PHYSICIAN NETWORK, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care