=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316275282
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TATIANA BACA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2009
-----------------------------------------------------
Last Update Date | 12/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 S ARROYO PKWY
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105-3911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-644-5884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2128 GLENROSE AVE
-----------------------------------------------------
City | ALTADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91001-5528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------