Provider Demographics
NPI:1114058641
Name:BACOY, CONRAD BALMES
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:BALMES
Last Name:BACOY
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 1:9070 W CHEYENNE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8935
Mailing Address - Country:US
Mailing Address - Phone:702-476-4990
Mailing Address - Fax:
Practice Address - Street 1:2401 UNIVERSITY PKWY STE 103
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2894
Practice Address - Country:US
Practice Address - Phone:941-444-5970
Practice Address - Fax:941-444-5971
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012742171W00000X
FLPT28218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171W00000XOther Service ProvidersContractor