Provider Demographics
NPI:1770008062
Name:BACCINO, JOHN M (RD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:BACCINO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-3400
Mailing Address - Country:US
Mailing Address - Phone:312-902-2040
Mailing Address - Fax:312-648-0155
Practice Address - Street 1:325 E H ST # 133
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801
Practice Address - Country:US
Practice Address - Phone:906-774-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2019-09-07
Deactivation Date:2019-08-06
Deactivation Code:
Reactivation Date:2019-09-07
Provider Licenses
StateLicense IDTaxonomies
IL164007146133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered