Provider Demographics
NPI:1821451758
Name:BACA, AMALIA
Entity Type:Individual
Prefix:
First Name:AMALIA
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W ROOSEVELT ST
Mailing Address - Street 2:2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-1376
Mailing Address - Country:US
Mailing Address - Phone:602-307-0888
Mailing Address - Fax:602-307-1002
Practice Address - Street 1:301 W ROOSEVELT ST
Practice Address - Street 2:2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-1376
Practice Address - Country:US
Practice Address - Phone:602-307-0888
Practice Address - Fax:602-307-1002
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16-1530175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath