Healthcare Provider Details

I. General information

NPI: 1619364650
Provider Name (Legal Business Name): IMPERIAL VALLEY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

578 G ST
BRAWLEY CA
92227-2411
US

IV. Provider business mailing address

578 G ST
BRAWLEY CA
92227-2411
US

V. Phone/Fax

Practice location:
  • Phone: 760-344-2157
  • Fax: 760-344-2203
Mailing address:
  • Phone: 760-344-2157
  • Fax: 760-344-2203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SOCORRO ESCALANTE
Title or Position: MANAGER
Credential:
Phone: 760-344-2157