Healthcare Provider Details

I. General information

NPI: 1962346742
Provider Name (Legal Business Name): BAO THE TRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 E ALESSANDRO BLVD
RIVERSIDE CA
92508-6071
US

IV. Provider business mailing address

11175 CAMPUS ST
LOMA LINDA CA
92350-1700
US

V. Phone/Fax

Practice location:
  • Phone: 951-780-1835
  • Fax:
Mailing address:
  • Phone: 909-558-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberINT51631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: