MEDICARE: CAMILLE BACCUS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	155961	OH

General Provider Information

NPI Number	:	1386035020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLE BACCUS

Provider Business Mailing Address
First Line	:	5228 SHASTA AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-9113
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5228 SHASTA AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-9113
Country	:	US
Telephone Number	:	937-732-1185
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2015
Last Update Date	:	02/17/2015

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Directions to “ CAMILLE BACCUS ” Practice Location

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