Provider Demographics
NPI:1750604302
Name:BACON, RODERICK J
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:J
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 1:18401 WINSLOW RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4800
Mailing Address - Country:US
Mailing Address - Phone:216-324-4779
Mailing Address - Fax:
Practice Address - Street 1:18401 WINSLOW RD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-4800
Practice Address - Country:US
Practice Address - Phone:216-324-4779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker