Provider Demographics
NPI:1902330285
Name:INNOVATIVE PAIN MANAGEMENT MEDICAL GROUP
Entity Type:Organization
Organization Name:INNOVATIVE PAIN MANAGEMENT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:D
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-434-4019
Mailing Address - Street 1:333 W HARBOR DR
Mailing Address - Street 2:SUITE 126
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7709
Mailing Address - Country:US
Mailing Address - Phone:619-434-4019
Mailing Address - Fax:619-434-4023
Practice Address - Street 1:610 EUCLID AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2951
Practice Address - Country:US
Practice Address - Phone:619-434-4019
Practice Address - Fax:619-434-4023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA732572081P2900X
CA261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty