Healthcare Provider Details

I. General information

NPI: 1538644802
Provider Name (Legal Business Name): BAY BACK CLINICAL INFUSIONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 IRVINE AVE STE 116
COSTA MESA CA
92627-6604
US

IV. Provider business mailing address

3943 IRVINE BLVD STE 628
IRVINE CA
92602-2400
US

V. Phone/Fax

Practice location:
  • Phone: 310-740-7864
  • Fax: 949-449-8325
Mailing address:
  • Phone: 310-740-7864
  • Fax: 949-449-8325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN EDWARD HUMISTON
Title or Position: FAMILY MEDICINE
Credential: MD
Phone: 619-550-7636