Provider Demographics
NPI:1902443724
Name:SACAY, LEX RES MARK BACUNAWA (DPT)
Entity Type:Individual
Prefix:
First Name:LEX RES MARK
Middle Name:BACUNAWA
Last Name:SACAY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 ORANGE TREE LN STE 200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4587
Mailing Address - Country:US
Mailing Address - Phone:909-557-1600
Mailing Address - Fax:909-557-1732
Practice Address - Street 1:15095 AMARGOSA RD STE 106
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-1875
Practice Address - Country:US
Practice Address - Phone:760-245-6495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-01
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT297592225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist