Provider Demographics
NPI:1134704042
Name:INNOVA PHYSICIAN NETWORK, INC.
Entity type:Organization
Organization Name:INNOVA PHYSICIAN NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:G
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-398-0354
Mailing Address - Street 1:1403 N FAIR OAKS AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1876
Mailing Address - Country:US
Mailing Address - Phone:626-398-0354
Mailing Address - Fax:
Practice Address - Street 1:1403 N FAIR OAKS AVE STE 3
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1876
Practice Address - Country:US
Practice Address - Phone:626-398-0354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty