Healthcare Provider Details

I. General information

NPI: 1851556492
Provider Name (Legal Business Name): IRIS G BACA LMT 5746
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 S MAIN ST SUITE 5A
LAS CRUCES NM
88005-6577
US

IV. Provider business mailing address

PO BOX 7443
LAS CRUCES NM
88006-7443
US

V. Phone/Fax

Practice location:
  • Phone: 575-640-8344
  • Fax:
Mailing address:
  • Phone: 575-640-8344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5746
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: