Provider Demographics
NPI:1770467888
Name:INNOVATIVE EXTENSIVIST GROUP PC
Entity type:Organization
Organization Name:INNOVATIVE EXTENSIVIST GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALMA
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-800-8330
Mailing Address - Street 1:44045 MARGARITA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-2729
Mailing Address - Country:US
Mailing Address - Phone:951-880-0701
Mailing Address - Fax:951-904-3647
Practice Address - Street 1:44045 MARGARITA RD STE 101
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2729
Practice Address - Country:US
Practice Address - Phone:951-880-0701
Practice Address - Fax:951-904-3647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-01
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty