MEDICARE: BRYAN JAMES BACA ATC, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL4461	FL
2	2255A2300X	Athletic Trainer	AT667	NM
3	2255A2300X	Athletic Trainer	AT5461	TX

General Provider Information

NPI Number	:	1881165082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN JAMES BACA ATC, CSCS

Provider Business Mailing Address
First Line	:	5454 N HAVERHILL RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-3006
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5454 N HAVERHILL RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-3006
Country	:	US
Telephone Number	:	713-376-6999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	12/16/2018

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