Healthcare Provider Details

I. General information

NPI: 1407981764
Provider Name (Legal Business Name): MR. PAUL R. K. BACON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 KINOOLE ST
HILO HI
96720-2816
US

IV. Provider business mailing address

15-2809 MAIKO ST
PAHOA HI
96778-9136
US

V. Phone/Fax

Practice location:
  • Phone: 808-933-0599
  • Fax: 808-933-0585
Mailing address:
  • Phone: 808-933-0598
  • Fax: 808-933-0585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: