Organization
GREG BACA MD, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GREGORY K BACA M.D. (OWNER)
(505) 795-5217
Entity
Organization
Contact information
Practice address
464 CENTRAL AVE, SUITE 4, LOS ALAMOS, NM 87544-3350
(505) 795-5217
Mailing address
112 GRAND CANYON DR, LOS ALAMOS, NM 87544-3423
(505) 795-5217
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
MD2008-0553
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
13252291
—
NM
Enumeration date
10/16/2013
Last updated
10/16/2013
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