Healthcare Provider Details

I. General information

NPI: 1487928123
Provider Name (Legal Business Name): INNOVATIVE FEDERAL OPERATIONS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 E VISTA WAY SUITE B
VISTA CA
92084-5535
US

IV. Provider business mailing address

640 E VISTA WAY SUITE B
VISTA CA
92084-5535
US

V. Phone/Fax

Practice location:
  • Phone: 760-536-4144
  • Fax: 888-415-8297
Mailing address:
  • Phone: 760-536-4144
  • Fax: 888-415-8297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberFHB101207653
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberB2009034145
License Number StateCA

VIII. Authorized Official

Name: MR. LARRY L WICK
Title or Position: CEO
Credential:
Phone: 760-889-9425