Provider Demographics
NPI:1609269125
Name:BACON, PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
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 1:2307 MARSEILLE CT
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7248
Mailing Address - Country:US
Mailing Address - Phone:813-951-2447
Mailing Address - Fax:
Practice Address - Street 1:13023 SUMMERFIELD SQUARE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7402
Practice Address - Country:US
Practice Address - Phone:813-677-9500
Practice Address - Fax:813-677-9511
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11462111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor