Provider Demographics
NPI:1407911381
Name:BACON, TIFFANI S (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:TIFFANI
Middle Name:S
Last Name:BACON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 CORNERSTONE CT W STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5930 CORNERSTONE CT W STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3772
Practice Address - Country:US
Practice Address - Phone:866-687-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10015225100000X, 2251P0200X
NC99002251P0200X, 225100000X
MDCP039211T-MD225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00405932OtherRAILROAD MEDICARE
SCTH2249Medicaid
MDCP039211T-MDOtherCOMPACT PT LICENSURE