Provider Demographics
NPI:1316914443
Name:BULACLAC, MARICRIS TAMAYO (PT)
Entity type:Individual
Prefix:MS
First Name:MARICRIS
Middle Name:TAMAYO
Last Name:BULACLAC
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 1:333 S CATALINA ST
Mailing Address - Street 2:APT. 315
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-2028
Mailing Address - Country:US
Mailing Address - Phone:213-487-3276
Mailing Address - Fax:213-487-3276
Practice Address - Street 1:333 S CATALINA ST
Practice Address - Street 2:APT. 315
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-2028
Practice Address - Country:US
Practice Address - Phone:213-386-8996
Practice Address - Fax:213-386-8996
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist