Healthcare Provider Details

I. General information

NPI: 1447809694
Provider Name (Legal Business Name): EUGENE PAUL BACOLOD PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15204 W COLONIAL DR
WINTER GARDEN FL
34787-6042
US

IV. Provider business mailing address

646 W SMITH ST UNIT 349
ORLANDO FL
32804-5381
US

V. Phone/Fax

Practice location:
  • Phone: 407-877-2394
  • Fax:
Mailing address:
  • Phone: 832-512-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number29471
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: