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General NPI Number Information
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NPI Number | 1548744915
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Entity Type | Individual
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Provider Name | RYAN BACA
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Gender | Male
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Dates
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Enumeration Date | 09/20/2018
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Last Update Date | 09/20/2018
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Provider Practice Location Address
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Address Line | 2010 N CAPITOL AVE
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City | INDIANAPOLIS
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State | IN
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Zip | 46202-1222
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Country | US
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Telephone | 317-924-5821
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Fax |
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Provider Business Mailing Address
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Address Line | 1002 BURGESS HILL PASS
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City | WESTFIELD
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State | IN
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Zip | 46074-5882
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Country | US
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Telephone | 630-531-4880
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 31006279A
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License Number State | IN
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