Provider Demographics
NPI:1285054908
Name:BACA, ERNIE STANLEY (MS)
Entity type:Individual
Prefix:
First Name:ERNIE
Middle Name:STANLEY
Last Name:BACA
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1007
Mailing Address - Country:US
Mailing Address - Phone:970-221-0999
Mailing Address - Fax:970-221-2727
Practice Address - Street 1:1644 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1007
Practice Address - Country:US
Practice Address - Phone:970-221-0999
Practice Address - Fax:970-221-2727
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0499136251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)