Provider Demographics
NPI:1891862553
Name:BASELINE MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:BASELINE MEDICAL CLINIC, INC
Other - Org Name:BASELINE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOANG-CHUONG
Authorized Official - Middle Name:N
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-888-6602
Mailing Address - Street 1:330 N D ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1522
Mailing Address - Country:US
Mailing Address - Phone:909-888-6602
Mailing Address - Fax:909-888-6619
Practice Address - Street 1:330 N D ST STE 300
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1522
Practice Address - Country:US
Practice Address - Phone:909-888-6602
Practice Address - Fax:909-885-7494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC27156261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0017240Medicaid
CAGR0017240Medicaid