Provider Demographics
NPI:1295981140
Name:BRUCE BACA PA
Entity type:Organization
Organization Name:BRUCE BACA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:806-322-1074
Mailing Address - Street 1:PO BOX 50862
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79159-0862
Mailing Address - Country:US
Mailing Address - Phone:806-322-1074
Mailing Address - Fax:806-322-1075
Practice Address - Street 1:7120 I-40 W
Practice Address - Street 2:SUITE 456
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2526
Practice Address - Country:US
Practice Address - Phone:806-322-1074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX080011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX108119202Medicaid
00S01BOtherBCBS TEXAS
TX108119202Medicaid