Healthcare Provider Details

I. General information

NPI: 1235673062
Provider Name (Legal Business Name): LOC BAO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W HOSPITAL RD
FRENCH CAMP CA
95231-9693
US

IV. Provider business mailing address

3037 VINTAGE WAY
MOODY AL
35004-3057
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-6000
  • Fax:
Mailing address:
  • Phone: 205-396-9132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number837202
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-133132
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: