Healthcare Provider Details

I. General information

NPI: 1750015616
Provider Name (Legal Business Name): BLUE LINE MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 WILLOW AVE STE 101
CLOVIS CA
93612-4714
US

IV. Provider business mailing address

1099 E. CHAMPLAIN DRIVE SUITE A #186
FRESNO CA
93720
US

V. Phone/Fax

Practice location:
  • Phone: 559-370-8694
  • Fax: 626-377-4221
Mailing address:
  • Phone: 559-370-8694
  • Fax: 626-377-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LEO L FONG
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 559-370-8694