Healthcare Provider Details

I. General information

NPI: 1093847733
Provider Name (Legal Business Name): GARY RONALD BAKER H. AID DISPENSER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 W ORANGEBURG AVE
MODESTO CA
95350-4042
US

IV. Provider business mailing address

1150 W ORANGEBURG AVE
MODESTO CA
95350-4042
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-9883
  • Fax: 209-526-8681
Mailing address:
  • Phone: 209-526-9883
  • Fax: 209-526-8681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number207
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License NumberSL1875
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License NumberCL325
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: