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General NPI Number Information
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NPI Number | 1679089288
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Entity Type | Individual
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Provider Name | TRACEY BACA DOM
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Gender | Female
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Dates
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Enumeration Date | 12/18/2017
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Last Update Date | 12/18/2017
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Provider Practice Location Address
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Address Line | 1209 SILVER AVE SW
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-2843
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Country | US
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Telephone | 505-730-0918
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Fax |
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Provider Business Mailing Address
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Address Line | 1209 SILVER AVE SW
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-2843
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Country | US
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Telephone | 505-730-0918
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 8363
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 1216
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License Number State | NM
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