Healthcare Provider Details

I. General information

NPI: 1891060208
Provider Name (Legal Business Name): NICHOLAS M BACA LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 PAN AMERICAN FWY NE UNIT 163
ALBUQUERQUE NM
87113-1824
US

IV. Provider business mailing address

8401 PAN AMERICAN FWY NE UNIT 163
ALBUQUERQUE NM
87113-1824
US

V. Phone/Fax

Practice location:
  • Phone: 505-999-6120
  • Fax:
Mailing address:
  • Phone: 505-999-6120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5648
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: