Provider Demographics
NPI:1851556492
Name:BACA, IRIS G (LMT 5746)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:G
Last Name:BACA
Suffix:
Gender:F
Credentials:LMT 5746
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7443
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88006-7443
Mailing Address - Country:US
Mailing Address - Phone:575-640-8344
Mailing Address - Fax:
Practice Address - Street 1:1625 S MAIN ST
Practice Address - Street 2:SUITE 5A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-6577
Practice Address - Country:US
Practice Address - Phone:575-640-8344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5746174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist