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General NPI Number Information
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NPI Number | 1902330285
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Entity Type | Organization
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Legal Business Name | INNOVATIVE PAIN MANAGEMENT MEDICAL GROUP
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Dates
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Enumeration Date | 04/13/2017
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Last Update Date | 04/13/2017
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Provider Practice Location Address
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Address Line | 610 EUCLID AVE SUITE 301
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City | NATIONAL CITY
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State | CA
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Zip | 91950-2951
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Country | US
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Telephone | 619-434-4019
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Fax | 619-434-4023
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Provider Business Mailing Address
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Address Line | 333 W HARBOR DR SUITE 126
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City | SAN DIEGO
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State | CA
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Zip | 92101-7709
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Country | US
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Telephone | 619-434-4019
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Fax | 619-434-4023
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRENTON D WYNN
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Credential | M.D.
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Telephone | 619-434-4019
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | A73257
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License Number State | CA
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