Provider Demographics
NPI:1568050367
Name:BACOD, POLLY ROSE A (NP)
Entity Type:Individual
Prefix:
First Name:POLLY ROSE
Middle Name:A
Last Name:BACOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22059 WINDHAM WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-5745
Mailing Address - Country:US
Mailing Address - Phone:661-714-2412
Mailing Address - Fax:
Practice Address - Street 1:100 W CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3010
Practice Address - Country:US
Practice Address - Phone:626-397-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA565027163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse