Healthcare Provider Details

I. General information

NPI: 1568050367
Provider Name (Legal Business Name): POLLY ROSE A BACOD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CALIFORNIA BLVD
PASADENA CA
91105-3010
US

IV. Provider business mailing address

22059 WINDHAM WAY
SANTA CLARITA CA
91350-5745
US

V. Phone/Fax

Practice location:
  • Phone: 626-397-5000
  • Fax:
Mailing address:
  • Phone: 661-714-2412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95017273
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number565027
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: