Provider Demographics
NPI:1255439402
Name:BACON, MARY L (DC)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:BACON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 GRAND AVE
Mailing Address - Street 2:SUITE 301C
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-4589
Mailing Address - Country:US
Mailing Address - Phone:510-663-1145
Mailing Address - Fax:510-663-1146
Practice Address - Street 1:230 GRAND AVE
Practice Address - Street 2:SUITE 301C
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4589
Practice Address - Country:US
Practice Address - Phone:510-663-1145
Practice Address - Fax:510-663-1146
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16993111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADCO169930Medicare ID - Type UnspecifiedMEDICARE PROVIDER #