Provider Demographics
NPI:1528239175
Name:BACCHUS, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 EXPOSITION BLVD
Mailing Address - Street 2:BLDG 700
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4314
Mailing Address - Country:US
Mailing Address - Phone:916-736-3399
Mailing Address - Fax:916-233-4179
Practice Address - Street 1:2 MEDICAL PLAZA DR
Practice Address - Street 2:STE 235
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3043
Practice Address - Country:US
Practice Address - Phone:916-782-1291
Practice Address - Fax:916-782-5992
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7250237600000X
CAAU2526231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07317ZMedicare PIN