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General NPI Number Information
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NPI Number | 1063866622
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Entity Type | Individual
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Provider Name | MR. BRENTON BACA
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Gender | Male
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Dates
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Enumeration Date | 04/20/2016
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Last Update Date | 04/20/2016
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Provider Practice Location Address
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Address Line | 55 JARAMILLO RD
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City | BELEN
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State | NM
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Zip | 87002-7335
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Country | US
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Telephone | 505-604-9956
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Fax |
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Provider Business Mailing Address
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Address Line | 55 JARAMILLO RD
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City | BELEN
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State | NM
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Zip | 87002-7335
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Country | US
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Telephone |
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 507226914
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License Number State | NM
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