Provider Demographics
NPI:1538644802
Name:BAY BACK CLINICAL INFUSIONS PC
Entity Type:Organization
Organization Name:BAY BACK CLINICAL INFUSIONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HUMISTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-550-7636
Mailing Address - Street 1:3943 IRVINE BLVD STE 628
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2400
Mailing Address - Country:US
Mailing Address - Phone:310-740-7864
Mailing Address - Fax:949-449-8325
Practice Address - Street 1:2675 IRVINE AVE STE 116
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-6604
Practice Address - Country:US
Practice Address - Phone:310-740-7864
Practice Address - Fax:949-449-8325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SYMMETRY MEDICAL INFUSIONS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty