Provider Demographics
NPI:1447843495
Name:BACOLOR, JUSTIN PATRICK
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PATRICK
Last Name:BACOLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2658 WILDHORSE TRAIL WAY
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-2542
Mailing Address - Country:US
Mailing Address - Phone:619-488-7430
Mailing Address - Fax:
Practice Address - Street 1:55 E JULIAN ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4007
Practice Address - Country:US
Practice Address - Phone:408-918-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program