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General NPI Number Information
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NPI Number | 1629659016
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Entity Type | Organization
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Legal Business Name | INNOVA PHYSICIAN NETWORK
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Dates
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Enumeration Date | 04/16/2021
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Last Update Date | 04/16/2021
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Provider Practice Location Address
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Address Line | 1403 N. FAIR OAKS AVENUE SUITE 3
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City | PASADENA
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State | CA
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Zip | 91103
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Country | US
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Telephone | 323-639-6593
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Fax | 626-398-0357
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Provider Business Mailing Address
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Address Line | 1403 N. FAIR OAKS AVENUE SUITE 3
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City | PASADENA
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State | CA
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Zip | 91103
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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 | DIRECTOR OF NETWORK DEVELOPMENT
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Name | JOON PARK
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Credential |
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Telephone | 323-639-6593
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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