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General NPI Number Information
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NPI Number | 1003012691
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Entity Type | Individual
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Provider Name | IRENE BACUS
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Gender | Female
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Dates
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Enumeration Date | 06/21/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3330 CENTRE LAKE DR
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City | ONTARIO
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State | CA
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Zip | 91761-1211
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Country | US
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Telephone | 909-974-4704
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Fax |
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Provider Business Mailing Address
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Address Line | 108 BREEZEWOOD ST
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City | CORONA
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State | CA
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Zip | 92879-1210
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Country | US
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Telephone | 951-271-1985
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 625372
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License Number State | CA
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