Basic Information
| Provider Information | |||||||||
| NPI: | 1538725130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACON | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5383 AUSTIN DR | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479606531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126141928 | ||||||||
| FaxNumber: | 7654491196 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 SAGAMORE PKWY W STE 400 | ||||||||
| Address2: | |||||||||
| City: | WEST LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479061500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654632200 | ||||||||
| FaxNumber: | 7654633625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2019 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05013332A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.