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NPI Code Detail

MEDICARE: BYRON DENARTUS BACON

MEDICARE: BYRON DENARTUS BACON
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
1171M00000XCase Manager/Care Coordinator

General Provider Information

NPI Number : 1962905745
Entity Type Code : Individual
Provider Name (Legal Business Name) : BYRON DENARTUS BACON
Provider Business Mailing Address
First Line : 9611 BROOKDALE DR STE 100-122
Second Line :
City : CHARLOTTE
State : NC
Zip : 28215-8719
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1016 EUCLID AVE
Second Line :
City : CHARLOTTE
State : NC
Zip : 28203-4520
Country : US
Telephone Number : 704-807-5699
Fax Number : 704-631-4574
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/17/2018
Last Update Date : 03/17/2018

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Directions to “ BYRON DENARTUS BACON ” Practice Location

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