Provider Demographics
NPI:1225870249
Name:BACALLAO, JAIRON ROBERTO
Entity type:Individual
Prefix:
First Name:JAIRON
Middle Name:ROBERTO
Last Name:BACALLAO
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 1:11811 SW 210TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-7000
Mailing Address - Country:US
Mailing Address - Phone:786-459-5786
Mailing Address - Fax:
Practice Address - Street 1:11811 SW 210TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-7000
Practice Address - Country:US
Practice Address - Phone:786-459-5786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician