Provider Demographics
NPI:1790835742
Name:TRIA, FELIZARDO BACARO (IDC)
Entity Type:Individual
Prefix:MR
First Name:FELIZARDO
Middle Name:BACARO
Last Name:TRIA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2987 MAKAHA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-1557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1145 STURGIS STREET
Practice Address - Street 2:NAVAL HOSPITAL
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278-8250
Practice Address - Country:US
Practice Address - Phone:760-830-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman