Healthcare Provider Details

I. General information

NPI: 1205435864
Provider Name (Legal Business Name): MONTANA AFFINITY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 N MOUNTAIN AVE STE 103
UPLAND CA
91786-0000
US

IV. Provider business mailing address

820 N MOUNTAIN AVE STE 103
UPLAND CA
91786-4163
US

V. Phone/Fax

Practice location:
  • Phone: 909-236-5575
  • Fax:
Mailing address:
  • Phone: 909-236-5575
  • Fax: 909-222-6936

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. JOSEPHINE BAISA MONTANA
Title or Position: OWNER
Credential: M.D.
Phone: 909-236-5575