Healthcare Provider Details

I. General information

NPI: 1003012691
Provider Name (Legal Business Name): IRENE BACUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 CENTRE LAKE DR
ONTARIO CA
91761-1211
US

IV. Provider business mailing address

108 BREEZEWOOD ST
CORONA CA
92879-1210
US

V. Phone/Fax

Practice location:
  • Phone: 909-974-4704
  • Fax:
Mailing address:
  • Phone: 951-271-1985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number625372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: