Provider Demographics
NPI:1831548197
Name:POOM MEDICAL CLINIC INC
Entity type:Organization
Organization Name:POOM MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:LIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:POOMMIPANIT-BAJON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-419-1187
Mailing Address - Street 1:16293 REGENCY RANCH RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-5654
Mailing Address - Country:US
Mailing Address - Phone:808-419-1187
Mailing Address - Fax:
Practice Address - Street 1:2055 N PERRIS BLVD STE E6
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2517
Practice Address - Country:US
Practice Address - Phone:951-940-4176
Practice Address - Fax:951-940-4038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 70122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty