Provider Demographics
NPI:1477904571
Name:GB EASTERN MEDICINE CLINIC,INC.
Entity Type:Organization
Organization Name:GB EASTERN MEDICINE CLINIC,INC.
Other - Org Name:GB EASTERN MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GASEON
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:657-245-3357
Mailing Address - Street 1:1352 IRVINE BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3549
Mailing Address - Country:US
Mailing Address - Phone:657-245-3357
Mailing Address - Fax:657-245-3297
Practice Address - Street 1:1352 IRVINE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3549
Practice Address - Country:US
Practice Address - Phone:657-245-3357
Practice Address - Fax:657-245-3297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 17039171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty