1891862553 NPI number — BASELINE MEDICAL CLINIC, INC

Table of content: (NPI 1891862553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891862553 NPI number — BASELINE MEDICAL CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BASELINE MEDICAL CLINIC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BASELINE MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891862553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 N D ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92401-1522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-888-6602
Provider Business Mailing Address Fax Number:
909-888-6619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 N D ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92401-1522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-888-6602
Provider Business Practice Location Address Fax Number:
909-885-7494
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VU
Authorized Official First Name:
HOANG-CHUONG
Authorized Official Middle Name:
N
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
909-888-6602

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  C27156 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0017240 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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