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General NPI Number Information
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NPI Number | 1316535776
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Entity Type | Organization
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Legal Business Name | INNOVATIVE WELLNESS CLINIC, INC., A NURSING CORPORATION
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Dates
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Enumeration Date | 12/31/2020
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Last Update Date | 01/31/2024
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Provider Practice Location Address
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Address Line | 10225 AUSTIN DR STE 105
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City | SPRING VALLEY
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State | CA
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Zip | 91978-1521
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Country | US
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Telephone | 858-648-0755
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Fax | 534-429-4287
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Provider Business Mailing Address
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Address Line | 750 OTAY LAKES RD # 111
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City | CHULA VISTA
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State | CA
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Zip | 91910-6915
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRIMARY CARE PROVIDER
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Name | DANIELLE ALEXIS GORDON
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Credential |
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Telephone | 858-648-0755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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