Healthcare Provider Details

I. General information

NPI: 1194683680
Provider Name (Legal Business Name): RYAN BACCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2026
Last Update Date: 01/13/2026
Certification Date: 01/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4009 BIRD VIEW CT
COOL CA
95614-9455
US

IV. Provider business mailing address

4009 BIRD VIEW CT
COOL CA
95614-9455
US

V. Phone/Fax

Practice location:
  • Phone: 916-784-4000
  • Fax:
Mailing address:
  • Phone: 916-784-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: