Provider Demographics
NPI:1760772586
Name:BACON, DEL GENE (LADC)
Entity Type:Individual
Prefix:MR
First Name:DEL
Middle Name:GENE
Last Name:BACON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 DOTTE DR
Mailing Address - Street 2:#103
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4369
Mailing Address - Country:US
Mailing Address - Phone:320-629-1362
Mailing Address - Fax:320-629-3454
Practice Address - Street 1:645 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1468
Practice Address - Country:US
Practice Address - Phone:320-629-1362
Practice Address - Fax:320-629-3454
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302602101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)