Provider Demographics
NPI:1447809694
Name:BACOLOD, EUGENE PAUL (PTA)
Entity type:Individual
Prefix:
First Name:EUGENE PAUL
Middle Name:
Last Name:BACOLOD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 W SMITH ST UNIT 349
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5381
Mailing Address - Country:US
Mailing Address - Phone:832-512-0505
Mailing Address - Fax:
Practice Address - Street 1:15204 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-6042
Practice Address - Country:US
Practice Address - Phone:407-877-2394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29471225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant