Provider Demographics
NPI:1487928123
Name:INNOVATIVE FEDERAL OPERATIONS GROUP
Entity type:Organization
Organization Name:INNOVATIVE FEDERAL OPERATIONS GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-889-9425
Mailing Address - Street 1:640 E VISTA WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5535
Mailing Address - Country:US
Mailing Address - Phone:760-536-4144
Mailing Address - Fax:888-415-8297
Practice Address - Street 1:640 E VISTA WAY
Practice Address - Street 2:SUITE B
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5535
Practice Address - Country:US
Practice Address - Phone:760-536-4144
Practice Address - Fax:888-415-8297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB2009034145335E00000X
CAFHB101207653332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA829402309OtherDUNS