Provider Demographics
NPI:1639740350
Name:BACON, ADRIAN ANGELO (LMT)
Entity Type:Individual
Prefix:MR
First Name:ADRIAN
Middle Name:ANGELO
Last Name:BACON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 N RISING STAR TRL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1060
Mailing Address - Country:US
Mailing Address - Phone:602-481-1001
Mailing Address - Fax:
Practice Address - Street 1:2510 N RISING STAR TRL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1060
Practice Address - Country:US
Practice Address - Phone:602-481-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-03
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-08176225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist