Healthcare Provider Details

I. General information

NPI: 1548186257
Provider Name (Legal Business Name): SAVANNAH RAE BACA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 MEADOWLARK LN SE
RIO RANCHO NM
87124-1021
US

IV. Provider business mailing address

4210 MEADOWLARK LN SE
RIO RANCHO NM
87124-1021
US

V. Phone/Fax

Practice location:
  • Phone: 505-560-9355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number84404
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: