Provider Demographics
NPI:1316255680
Name:LESLIE A BAIN MD MEDICAL CORPORATION
Entity type:Organization
Organization Name:LESLIE A BAIN MD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-720-9170
Mailing Address - Street 1:1441 AVOCADO AVE
Mailing Address - Street 2:SUITE 706
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7721
Mailing Address - Country:US
Mailing Address - Phone:949-720-9170
Mailing Address - Fax:949-720-0755
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:SUITE 706
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7721
Practice Address - Country:US
Practice Address - Phone:949-720-9170
Practice Address - Fax:949-720-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24274174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A24274AOtherMEDICARE ID
A24274AOtherMEDICARE ID