Healthcare Provider Details

I. General information

NPI: 1376756486
Provider Name (Legal Business Name): DAVID ROBERT BACA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W VICTORIA ST
GARDENA CA
90248-3523
US

IV. Provider business mailing address

2210 VANDERBILT LN APT# 20
REDONDO BEACH CA
90278-3148
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-2020
  • Fax:
Mailing address:
  • Phone: 310-372-5936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: