Healthcare Provider Details

I. General information

NPI: 1548059082
Provider Name (Legal Business Name): MR. ELISHA BACON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2025
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5530
US

IV. Provider business mailing address

4803 WELLINGTON WAY SW
VERO BEACH FL
32968-2338
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax:
Mailing address:
  • Phone: 772-925-2399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: