Provider Demographics
NPI:1306093661
Name:BACOLOD, MAIDEN LOUISE AXALAN (PT)
Entity type:Individual
Prefix:MS
First Name:MAIDEN LOUISE
Middle Name:AXALAN
Last Name:BACOLOD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W 7TH ST
Mailing Address - Street 2:APT 6
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-1569
Mailing Address - Country:US
Mailing Address - Phone:708-990-6217
Mailing Address - Fax:
Practice Address - Street 1:900 S CHESTNUT
Practice Address - Street 2:PRAIRIE ROSE HEALTHCARE CENTER
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557
Practice Address - Country:US
Practice Address - Phone:217-562-3996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist