Provider Demographics
NPI:1871777961
Name:IMPERIAL VALLEY WOMENS CLINIC
Entity type:Organization
Organization Name:IMPERIAL VALLEY WOMENS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LINDA
Authorized Official - Last Name:SLADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-353-3331
Mailing Address - Street 1:495 E ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2744
Mailing Address - Country:US
Mailing Address - Phone:760-353-3331
Mailing Address - Fax:760-353-5085
Practice Address - Street 1:495 E ORANGE AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2744
Practice Address - Country:US
Practice Address - Phone:760-353-3331
Practice Address - Fax:760-353-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C503030207V00000X
CA00G486850207V00000X
CA00A395830207V00000X
CA437781207VX0000X
CA529623363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ79332ZMedicaid
CALAB72222FMedicaid
CAW11348Medicare PIN