Provider Demographics
NPI:1639457153
Name:RAINER G. BANSUAN MD INC
Entity Type:Organization
Organization Name:RAINER G. BANSUAN MD INC
Other - Org Name:BANSUAN MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAINER
Authorized Official - Middle Name:G
Authorized Official - Last Name:BANSUAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-455-0982
Mailing Address - Street 1:10305 GARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-2135
Mailing Address - Country:US
Mailing Address - Phone:626-455-0982
Mailing Address - Fax:626-455-0984
Practice Address - Street 1:10305 GARVEY AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-2135
Practice Address - Country:US
Practice Address - Phone:626-455-0982
Practice Address - Fax:626-455-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51021261Q00000X, 261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51021Medicaid