Healthcare Provider Details

I. General information

NPI: 1982079273
Provider Name (Legal Business Name): MR. KEVIN BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7027 MONTGOMERY BLVD NE SUITE F
ALBUQUERQUE NM
87109-1589
US

IV. Provider business mailing address

7027 MONTGOMERY BLVD NE SUITE F
ALBUQUERQUE NM
87109-1589
US

V. Phone/Fax

Practice location:
  • Phone: 505-880-0102
  • Fax: 505-880-0102
Mailing address:
  • Phone: 505-880-0102
  • Fax: 505-880-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: