=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518426857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE TREATMENT ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2019
-----------------------------------------------------
Last Update Date | 04/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3581 PALMER DR STE 601
-----------------------------------------------------
City | CAMERON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95682-8238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-556-5363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3116 CASTLEWOOD CIR
-----------------------------------------------------
City | POLLOCK PINES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95726-9522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-391-9309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | JOHN RULISON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 530-391-9196
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------