Provider Demographics
NPI:1407911381
Name:BACON, TIFFANI S (MPT)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANI
Middle Name:S
Last Name:BACON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 COMMERCIAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3851 COMMERCIAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4146
Practice Address - Country:US
Practice Address - Phone:888-510-6369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900225100000X, 2251P0200X
SC100152251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00405932OtherRAILROAD MEDICARE
SCTH2249Medicaid