Provider Demographics
NPI:1972953263
Name:BACON, JAMES WESLEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WESLEY
Last Name:BACON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 S ROCK RD APT 810
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-5177
Mailing Address - Country:US
Mailing Address - Phone:316-734-4508
Mailing Address - Fax:
Practice Address - Street 1:1770 S ROCK RD APT 810
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-5177
Practice Address - Country:US
Practice Address - Phone:316-734-4508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-02894225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1336253764Medicare PIN