Healthcare Provider Details

I. General information

NPI: 1962527606
Provider Name (Legal Business Name): BASKERVILLE, BENNETT, BLOCK & LIU, A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 GREEN VALLEY RD
FREEDOM CA
95019-3138
US

IV. Provider business mailing address

4145 CLARES ST SUITE A
CAPITOLA CA
95010-2053
US

V. Phone/Fax

Practice location:
  • Phone: 831-475-7442
  • Fax: 831-475-7417
Mailing address:
  • Phone: 831-475-7442
  • Fax: 831-475-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES BENNETT
Title or Position: OWNER
Credential: M.D.
Phone: 831-763-4310