Provider Demographics
NPI:1003147810
Name:BACON, COREY EUGENE
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:EUGENE
Last Name:BACON
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 1:637 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-2775
Mailing Address - Country:US
Mailing Address - Phone:989-916-7243
Mailing Address - Fax:
Practice Address - Street 1:200 E CHISHOLM ST
Practice Address - Street 2:SUITE C
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-5800
Practice Address - Country:US
Practice Address - Phone:989-916-7243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCAOM113675171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist