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General NPI Number Information
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NPI Number | 1881165082
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Entity Type | Individual
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Provider Name | BRYAN JAMES BACA ATC, CSCS
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Gender | Male
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Dates
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Enumeration Date | 12/16/2018
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Last Update Date | 12/16/2018
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Provider Practice Location Address
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Address Line | 5454 N HAVERHILL RD
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City | WEST PALM BEACH
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State | FL
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Zip | 33407-3006
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Country | US
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Telephone | 713-376-6999
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Fax |
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Provider Business Mailing Address
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Address Line | 5454 N HAVERHILL RD
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City | WEST PALM BEACH
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State | FL
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Zip | 33407-3006
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL4461
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT667
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT5461
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License Number State | TX
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