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General NPI Number Information
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NPI Number | 1558576165
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Entity Type | Organization
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Legal Business Name | GEORGE BACA MD, LLC
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5808 MCLEOD RD NE SUITE K
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-2455
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Country | US
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Telephone | 505-872-2929
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Fax | 505-872-9503
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Provider Business Mailing Address
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Address Line | 5808 MCLEOD RD NE SUITE K
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-2455
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Country | US
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Telephone | 505-872-2929
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Fax | 505-872-9503
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Authorized Official
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Title or Position | DIRECTOR
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Name | GEORGE MARK BACA
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Credential | MD
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Telephone | 505-872-2929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 89-5
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License Number State | NM
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