Provider Demographics
NPI:1437482841
Name:BACA, ROBERTO (RN)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:BACA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 49
Mailing Address - Street 2:COMPLEX D RUSTLING WILLOW ST
Mailing Address - City:TOWAOC
Mailing Address - State:CO
Mailing Address - Zip Code:81334-0049
Mailing Address - Country:US
Mailing Address - Phone:970-565-4441
Mailing Address - Fax:970-565-9163
Practice Address - Street 1:232 RUSTLING WILLOW ST COMPLEX D
Practice Address - Street 2:
Practice Address - City:TOWAOC
Practice Address - State:CO
Practice Address - Zip Code:81334-0049
Practice Address - Country:US
Practice Address - Phone:970-565-4441
Practice Address - Fax:970-565-9163
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN-120269163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse