Healthcare Provider Details

I. General information

NPI: 1316535776
Provider Name (Legal Business Name): INNOVATIVE WELLNESS CLINIC, INC., A NURSING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2020
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10225 AUSTIN DR STE 105
SPRING VALLEY CA
91978-1521
US

IV. Provider business mailing address

750 OTAY LAKES RD # 111
CHULA VISTA CA
91910-6915
US

V. Phone/Fax

Practice location:
  • Phone: 858-648-0755
  • Fax: 534-429-4287
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE ALEXIS GORDON
Title or Position: PRIMARY CARE PROVIDER
Credential:
Phone: 858-648-0755