Provider Demographics
NPI:1205326634
Name:BACZEK, MARLENE A (ACUPUNCTURIST, MT)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:A
Last Name:BACZEK
Suffix:
Gender:F
Credentials:ACUPUNCTURIST, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 BATTLECREEK DR APT 15105
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-6272
Mailing Address - Country:US
Mailing Address - Phone:847-361-6398
Mailing Address - Fax:
Practice Address - Street 1:2001 S. SHIELDS, BLDG B, STE 2
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526
Practice Address - Country:US
Practice Address - Phone:847-361-6398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019569225700000X
CO0002243171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist