Provider Demographics
NPI:1467726927
Name:BACON, ELTON E (BOC/ABC)
Entity Type:Individual
Prefix:
First Name:ELTON
Middle Name:E
Last Name:BACON
Suffix:
Gender:M
Credentials:BOC/ABC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JARRETT WHITE RD DEPT OF THE ARMY
Mailing Address - Street 2:ATTN: ORTHOPEDIC BRACE CLINIC (MCHK-DSO-A)
Mailing Address - City:TRIPLER AMC
Mailing Address - State:HI
Mailing Address - Zip Code:96859
Mailing Address - Country:US
Mailing Address - Phone:808-433-6967
Mailing Address - Fax:808-433-9227
Practice Address - Street 1:1 JARRETT WHITE RD DEPT OF THE ARMY
Practice Address - Street 2:ATTN: ORTHOPEDIC BRACE CLINIC (MCHK-DSO-A)
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859
Practice Address - Country:US
Practice Address - Phone:808-433-6967
Practice Address - Fax:808-433-9227
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HICO004280OtherABC
HIC13175OtherBOC