Provider Demographics
NPI:1184694994
Name:BACON, ENRIQUE (ATC)
Entity type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:
Last Name:BACON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 TERRA SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:VOLO
Mailing Address - State:IL
Mailing Address - Zip Code:60020-3201
Mailing Address - Country:US
Mailing Address - Phone:815-814-8867
Mailing Address - Fax:
Practice Address - Street 1:929 W HIGGINS RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60195-3203
Practice Address - Country:US
Practice Address - Phone:847-885-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-002119174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist