Provider Demographics
NPI:1376623181
Name:BACON, ROBERT THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:THOMAS
Last Name:BACON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 PAULS WAY
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-1465
Mailing Address - Country:US
Mailing Address - Phone:770-693-8026
Mailing Address - Fax:
Practice Address - Street 1:736 JOHNSON FERRY RD STE C130
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5628
Practice Address - Country:US
Practice Address - Phone:404-433-6574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007778111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor