Healthcare Provider Details

I. General information

NPI: 1174339949
Provider Name (Legal Business Name): IMPERIAL VALLEY WOUND CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 4TH ST STE C
CALEXICO CA
92231-2714
US

IV. Provider business mailing address

200 E 4TH ST STE C
CALEXICO CA
92231-2714
US

V. Phone/Fax

Practice location:
  • Phone: 818-906-4466
  • Fax:
Mailing address:
  • Phone: 818-906-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIANNE CRYSTAL GOBER
Title or Position: CEO/OWNER
Credential: MD
Phone: 818-906-4466