Provider Demographics
NPI:1992170575
Name:INNOVAGE HEALTH PARTNERS, INC.
Entity type:Organization
Organization Name:INNOVAGE HEALTH PARTNERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-974-2459
Mailing Address - Street 1:410 E PARKCENTER CIR N
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2869
Mailing Address - Country:US
Mailing Address - Phone:909-890-2800
Mailing Address - Fax:909-890-9615
Practice Address - Street 1:410 E PARKCENTER CIR N
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2869
Practice Address - Country:US
Practice Address - Phone:909-890-2800
Practice Address - Fax:909-890-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53735207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty