Healthcare Provider Details

I. General information

NPI: 1295359750
Provider Name (Legal Business Name): SEVERO BACA III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 GIBSON BLVD SE APT 144
ALBUQUERQUE NM
87108-5391
US

IV. Provider business mailing address

5600 GIBSON BLVD SE APT 144
ALBUQUERQUE NM
87108-5391
US

V. Phone/Fax

Practice location:
  • Phone: 505-404-8133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: