Healthcare Provider Details

I. General information

NPI: 1447094263
Provider Name (Legal Business Name): GEORGIA BACA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 7TH ST
LAS VEGAS NM
87701-4958
US

IV. Provider business mailing address

117 CAMINO DE VIDA STE 300
SANTA ROSA NM
88435-2267
US

V. Phone/Fax

Practice location:
  • Phone: 505-587-1050
  • Fax: 877-553-1272
Mailing address:
  • Phone: 575-472-4311
  • Fax: 877-651-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: