Provider Demographics
NPI:1225464944
Name:BACA, JOHN ALFREDO
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALFREDO
Last Name:BACA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 COORS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1213
Mailing Address - Country:US
Mailing Address - Phone:505-338-3320
Mailing Address - Fax:505-338-3319
Practice Address - Street 1:2551 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1213
Practice Address - Country:US
Practice Address - Phone:505-338-3320
Practice Address - Fax:505-338-3319
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor