Healthcare Provider Details

I. General information

NPI: 1538058359
Provider Name (Legal Business Name): MED-LINE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11387 POPLAR STREET
LOMA LINDA CA
92354
US

IV. Provider business mailing address

PO BOX 904
REDLANDS CA
92373
US

V. Phone/Fax

Practice location:
  • Phone: 617-299-6398
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084S0010X
TaxonomySports Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State
# 15
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: N AGRAWAL
Title or Position: MANAGER
Credential:
Phone: 617-299-6398