Healthcare Provider Details

I. General information

NPI: 1902330285
Provider Name (Legal Business Name): INNOVATIVE PAIN MANAGEMENT MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 EUCLID AVE SUITE 301
NATIONAL CITY CA
91950-2951
US

IV. Provider business mailing address

333 W HARBOR DR SUITE 126
SAN DIEGO CA
92101-7709
US

V. Phone/Fax

Practice location:
  • Phone: 619-434-4019
  • Fax: 619-434-4023
Mailing address:
  • Phone: 619-434-4019
  • Fax: 619-434-4023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA73257
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: BRENTON D WYNN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-434-4019