Provider Demographics
NPI:1821105693
Name:BACON, MARCUS
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:BACON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 FARMINGTON AVE
Mailing Address - Street 2:P.O. BOX 452
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037
Mailing Address - Country:US
Mailing Address - Phone:860-829-5511
Mailing Address - Fax:
Practice Address - Street 1:1138 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037
Practice Address - Country:US
Practice Address - Phone:860-829-5511
Practice Address - Fax:860-829-5577
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT007144OtherLICENSE#