Healthcare Provider Details

I. General information

NPI: 1871777961
Provider Name (Legal Business Name): IMPERIAL VALLEY WOMENS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 E ORANGE AVE
EL CENTRO CA
92243-2744
US

IV. Provider business mailing address

495 E ORANGE AVE
EL CENTRO CA
92243-2744
US

V. Phone/Fax

Practice location:
  • Phone: 760-353-3331
  • Fax: 760-353-5085
Mailing address:
  • Phone: 760-353-3331
  • Fax: 760-353-5085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number00G486850
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number00A395830
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number529623
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number437781
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number00C503030
License Number StateCA

VIII. Authorized Official

Name: MISS MARY LINDA SLADE
Title or Position: OFFICE MANAGER
Credential:
Phone: 760-353-3331