Provider Demographics
NPI:1972396679
Name:BAXTER, MYLES
Entity type:Individual
Prefix:
First Name:MYLES
Middle Name:
Last Name:BAXTER
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 1:7974 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-6937
Mailing Address - Country:US
Mailing Address - Phone:916-509-2601
Mailing Address - Fax:
Practice Address - Street 1:7974 COBB ST
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-6937
Practice Address - Country:US
Practice Address - Phone:916-509-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA345920253310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility