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General NPI Number Information
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NPI Number | 1992170575
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Entity Type | Organization
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Legal Business Name | INNOVAGE HEALTH PARTNERS, INC.
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Dates
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Enumeration Date | 12/08/2015
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Last Update Date | 12/08/2015
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Provider Practice Location Address
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Address Line | 410 E PARKCENTER CIR N
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City | SAN BERNARDINO
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State | CA
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Zip | 92408-2869
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Country | US
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Telephone | 909-890-2800
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Fax | 909-890-9615
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Provider Business Mailing Address
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Address Line | 410 E PARKCENTER CIR N
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City | SAN BERNARDINO
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State | CA
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Zip | 92408-2869
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Country | US
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Telephone | 909-890-2800
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Fax | 909-890-9615
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Authorized Official
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Title or Position | CHIEF LEGAL OFFICER
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Name | VANESSA D WALTON
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Credential |
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Telephone | 720-974-2459
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | 53735
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License Number State | CA
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