Healthcare Provider Details

I. General information

NPI: 1265392674
Provider Name (Legal Business Name): IMPERIAL VALLEY PAIN & WELLNESS MANAGEMENT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 BROADWAY AVE STE F
EL CENTRO CA
92243-2451
US

IV. Provider business mailing address

485 BROADWAY AVE STE F
EL CENTRO CA
92243-2451
US

V. Phone/Fax

Practice location:
  • Phone: 760-970-4064
  • Fax: 619-304-1580
Mailing address:
  • Phone: 760-970-4064
  • Fax: 619-304-1580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SHARRON LOTUS THOMPSON
Title or Position: OWNER
Credential: MD
Phone: 760-970-4064