Healthcare Provider Details

I. General information

NPI: 1700612322
Provider Name (Legal Business Name): BASHNONA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20311 SW ACACIA ST STE 100
NEWPORT BEACH CA
92660-1733
US

IV. Provider business mailing address

20311 SW ACACIA ST STE 100
NEWPORT BEACH CA
92660-1733
US

V. Phone/Fax

Practice location:
  • Phone: 949-520-1620
  • Fax: 949-520-1550
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOCHA ANDREWS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 949-520-1620