NPIMap

Organization Active NPI

Innovative Wellness Clinic, Inc., a Nursing Corporation

Doing business as IWC Primary Care

  • Family Medicine Physician
  • Spring Valley, CA
National Provider Identifier
1316535776
Registry record updated Jan 31, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
INNOVATIVE WELLNESS CLINIC, INC., A NURSING CORPORATION
Doing business as
IWC Primary Care
Practice address
10225 Austin Dr
Ste 105
Spring Valley, CA 91978-1521
Phone
(858) 648-0755
Fax
(534) 429-4287
NPI assigned
Dec 31, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 31, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Danielle Alexis GordonNPI 1780148056
Title
Primary Care Provider
Phone
(858) 648-0755

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

10225 Austin Dr
Ste 105
Spring Valley, CA 91978-1521

Mailing address

750 Otay Lakes Rd # 111
Chula Vista, CA 91910-6915

Other identifiers 2

IdentifierTypeStateIssuer
A49264OtherCAMEDICAL LICENSE
NP95010963OtherCANURSE PRACTITIONER LICENSE NUMBER

Other names 1

  • IWC Primary Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211101002777 CA Part B Supplier - Clinic/Group Practice 9830587427 Receives reassigned benefits from 6 practitioners
Practice locations: Spring Valley, CA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D2216014Iwc Primary Care10225 Austin Dr Ste 105, Spring Valley, CA 91978Provider-performed microscopyMar 8, 2027

National Provider Directory

National Provider Directory

Locations

9239 Campo Rd
Ste A
Spring Valley, CA 91977
Phone (858) 648-0755

10225 Austin Dr
Ste 105
Spring Valley, CA 91978
Phone (619) 444-7796

Interoperability endpoints

  • Direct secure messaging: npdanielle@org77.direct.charmhealth.com

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1609372800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1706659200000",
    "number": "1316535776",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "750 OTAY LAKES RD # 111",
            "city": "CHULA VISTA",
            "state": "CA",
            "postal_code": "919106915"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10225 AUSTIN DR",
            "address_2": "STE 105",
            "city": "SPRING VALLEY",
            "state": "CA",
            "postal_code": "919781521",
            "telephone_number": "858-648-0755",
            "fax_number": "534-429-4287"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INNOVATIVE WELLNESS CLINIC, INC., A NURSING CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-12-31",
        "last_updated": "2024-01-31",
        "certification_date": "2024-01-31",
        "status": "A",
        "authorized_official_last_name": "GORDON",
        "authorized_official_first_name": "DANIELLE",
        "authorized_official_middle_name": "ALEXIS",
        "authorized_official_title_or_position": "PRIMARY CARE PROVIDER",
        "authorized_official_telephone_number": "858-648-0755"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE",
            "identifier": "A49264",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NURSE PRACTITIONER LICENSE NUMBER",
            "identifier": "NP95010963",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "IWC Primary Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Spring Valley, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 31, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.