MEDICARE: PEUANG BACCAM

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	3747P1801X	Personal Care Attendant		MN

General Provider Information

NPI Number	:	1992927602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PEUANG BACCAM

Provider Business Mailing Address
First Line	:	7515 11TH AVE S
Second Line	:
City	:	RICHFIELD
State	:	MN
Zip	:	55423-4504
Country	:	US
Telephone Number	:	612-861-2337
Fax Number	:

Provider Business Practice Location Address
First Line	:	7515 11TH AVE S
Second Line	:
City	:	RICHFIELD
State	:	MN
Zip	:	55423-4504
Country	:	US
Telephone Number	:	612-861-2337
Fax Number	:

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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Directions to “ PEUANG BACCAM ” Practice Location

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