Provider Demographics
NPI:1720398159
Name:BACA, ANTHONY JACOB JR
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JACOB
Last Name:BACA
Suffix:JR
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 1:5105 SMOKE RANCH RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-3536
Mailing Address - Country:US
Mailing Address - Phone:702-638-0395
Mailing Address - Fax:702-638-0362
Practice Address - Street 1:5105 SMOKE RANCH RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-3536
Practice Address - Country:US
Practice Address - Phone:702-638-0395
Practice Address - Fax:702-638-0362
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner