Provider Demographics
NPI:1003012691
Name:BACUS, IRENE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:BACUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 BREEZEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-1210
Mailing Address - Country:US
Mailing Address - Phone:951-271-1985
Mailing Address - Fax:
Practice Address - Street 1:3330 CENTRE LAKE DR
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-1211
Practice Address - Country:US
Practice Address - Phone:909-974-4704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA625372163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse