1922071984 NPI number — R BACON ENTERPRISES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922071984 NPI number — R BACON ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
R BACON ENTERPRISES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922071984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
966 N BAKER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47601-9509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-897-1904
Provider Business Mailing Address Fax Number:
812-897-0620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
966 N BAKER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47601-9509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-897-1904
Provider Business Practice Location Address Fax Number:
812-897-0620
Provider Enumeration Date:
02/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BACON
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
812-897-1904

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  FDA1835621 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000193499 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000335186 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 286867 . This is a "HARMONY HEALTH PLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000107530 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8200169 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000097303 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000193509 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0742058 . This is a "UMWA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1023713 . This is a "ACM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000335185 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 90009473 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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