Provider Demographics
NPI:1194507061
Name:MAQUILING, IRWIN
Entity type:Individual
Prefix:
First Name:IRWIN
Middle Name:
Last Name:MAQUILING
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 1:3169 ADELAIDE LOOP
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-4282
Mailing Address - Country:US
Mailing Address - Phone:847-840-8808
Mailing Address - Fax:
Practice Address - Street 1:3169 ADELAIDE LOOP
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-4282
Practice Address - Country:US
Practice Address - Phone:847-840-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty