Healthcare Provider Details

I. General information

NPI: 1568466811
Provider Name (Legal Business Name): LORETTA L. BACA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S JEFFERS ST
NORTH PLATTE NE
69101-5349
US

IV. Provider business mailing address

302 S JEFFERS ST
NORTH PLATTE NE
69101-5349
US

V. Phone/Fax

Practice location:
  • Phone: 308-534-6687
  • Fax: 308-534-1874
Mailing address:
  • Phone: 308-534-6687
  • Fax: 308-534-1874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number19678
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: