Provider Demographics
NPI:1700949245
Name:INJURY AND WELLNESS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:INJURY AND WELLNESS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-434-5633
Mailing Address - Street 1:PO BOX 6026
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-6026
Mailing Address - Country:US
Mailing Address - Phone:805-434-3563
Mailing Address - Fax:
Practice Address - Street 1:292 POSADA LN
Practice Address - Street 2:SUITE A
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4054
Practice Address - Country:US
Practice Address - Phone:805-434-5633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16640Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER