Provider Demographics
NPI:1205132586
Name:BACON, MICHEL LARS
Entity type:Individual
Prefix:MR
First Name:MICHEL
Middle Name:LARS
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 1:102 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3041
Mailing Address - Country:US
Mailing Address - Phone:307-529-0164
Mailing Address - Fax:
Practice Address - Street 1:102 W 27TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3041
Practice Address - Country:US
Practice Address - Phone:307-529-0164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services