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General NPI Number Information
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NPI Number | 1770467888
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Entity Type | Organization
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Legal Business Name | INNOVATIVE EXTENSIVIST GROUP PC
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Dates
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Enumeration Date | 08/01/2025
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Last Update Date | 08/12/2025
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Provider Practice Location Address
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Address Line | 44045 MARGARITA RD STE 101
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City | TEMECULA
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State | CA
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Zip | 92592-2729
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Country | US
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Telephone | 951-880-0701
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Fax | 951-904-3647
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Provider Business Mailing Address
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Address Line | 44045 MARGARITA RD STE 101
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City | TEMECULA
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State | CA
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Zip | 92592-2729
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Country | US
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Telephone | 951-880-0701
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Fax | 951-904-3647
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | ALMA TORRES
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Credential |
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Telephone | 951-800-8330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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