Healthcare Provider Details

I. General information

NPI: 1720097371
Provider Name (Legal Business Name): BRUCE RICHARD BACON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-0001
US

IV. Provider business mailing address

2232 W GLEN HILLS CT
GLENDALE WI
53209-3353
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax:
Mailing address:
  • Phone: 414-540-0772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0400X
TaxonomyRehabilitation Registered Nurse
License Number122292-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: