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1407911381

NPI Code Detail

MEDICARE: MRS. TIFFANI S BACON PT, DPT

MEDICARE: MRS. TIFFANI S BACON PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	10015	SC
2	2251P0200X	Pediatric Physical Therapist	9900	NC
3	225100000X	Physical Therapist	9900	NC
4	2251P0200X	Pediatric Physical Therapist	10015	SC
5	225100000X	Physical Therapist	CP039211T-MD	MD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00405932	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	CP039211T-MD	OTHER	MD	COMPACT PT LICENSURE

General Provider Information

NPI Number	:	1407911381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIFFANI S BACON PT, DPT

Provider Business Mailing Address
First Line	:	5930 CORNERSTONE CT W STE 300
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3772
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5930 CORNERSTONE CT W STE 300
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3772
Country	:	US
Telephone Number	:	866-687-7390
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	01/15/2025

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Directions to “ MRS. TIFFANI S BACON PT, DPT” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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