Healthcare Provider Details

I. General information

NPI: 1639238132
Provider Name (Legal Business Name): MRS. CASLENE C BACCHUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 JEROME AVE
BRONX NY
10467-1052
US

IV. Provider business mailing address

1360 EDWARDS AVE
BRONX NY
10461-5805
US

V. Phone/Fax

Practice location:
  • Phone: 718-881-7600
  • Fax: 718-654-1465
Mailing address:
  • Phone: 718-239-4937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number462893-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: