Provider Demographics
NPI:1326877812
Name:BAUM, MICKEY
Entity type:Individual
Prefix:
First Name:MICKEY
Middle Name:
Last Name:BAUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 QUINCY CANYON RD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-1506
Mailing Address - Country:US
Mailing Address - Phone:619-933-0192
Mailing Address - Fax:
Practice Address - Street 1:460 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3610
Practice Address - Country:US
Practice Address - Phone:619-933-0192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95290204163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation