Provider Demographics
NPI:1720097371
Name:BACON, BRUCE RICHARD (RN)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:RICHARD
Last Name:BACON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2232 W GLEN HILLS CT
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3353
Mailing Address - Country:US
Mailing Address - Phone:414-540-0772
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122292-30163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation