Provider Demographics
NPI:1922071984
Name:R BACON ENTERPRISES INC
Entity Type:Organization
Organization Name:R BACON ENTERPRISES INC
Other - Org Name:FREEDOM MEDICAL BOONVILLE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-897-1904
Mailing Address - Street 1:966 N BAKER RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-9509
Mailing Address - Country:US
Mailing Address - Phone:812-897-1904
Mailing Address - Fax:812-897-0620
Practice Address - Street 1:966 N BAKER RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-9509
Practice Address - Country:US
Practice Address - Phone:812-897-1904
Practice Address - Fax:812-897-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INFDA1835621332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000193499OtherANTHEM
000000335186OtherANTHEM
IN286867OtherHARMONY HEALTH PLAN
000000107530OtherANTHEM
8200169OtherUNITED HEALTHCARE
000000097303OtherANTHEM
000000193509OtherANTHEM
0742058OtherUMWA
IN1023713OtherACM
000000335185OtherANTHEM
KY90009473Medicaid
IN286867OtherHARMONY HEALTH PLAN
000000335186OtherANTHEM
0249290003Medicare ID - Type Unspecified