Provider Demographics
NPI:1417203233
Name:BACON, CHARLES STEWART (DPT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:STEWART
Last Name:BACON
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 1:1503 WASHINGTON LN
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KS
Mailing Address - Zip Code:67010-1638
Mailing Address - Country:US
Mailing Address - Phone:316-775-0700
Mailing Address - Fax:316-775-9007
Practice Address - Street 1:1503 WASHINGTON LN
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KS
Practice Address - Zip Code:67010-1638
Practice Address - Country:US
Practice Address - Phone:316-775-0700
Practice Address - Fax:316-775-9007
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-04429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist