=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851106447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. ALEX KEITH BACON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 SANCTUARY LN
-----------------------------------------------------
City | COLUMBIANA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35051-5435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-259-6245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CMR 467 BOX 5194
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AE
-----------------------------------------------------
Zip | 09096-1052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-333-8368
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------