Provider Demographics
NPI:1104434075
Name:INNOVATIVE NEUROLOGY, INC.
Entity type:Organization
Organization Name:INNOVATIVE NEUROLOGY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:RAQUEL
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-306-1127
Mailing Address - Street 1:24671 MONROE AVE # C102
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-9589
Mailing Address - Country:US
Mailing Address - Phone:951-797-4446
Mailing Address - Fax:833-989-2495
Practice Address - Street 1:24671 MONROE AVE # C102
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9589
Practice Address - Country:US
Practice Address - Phone:951-797-4446
Practice Address - Fax:833-989-2495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty