Provider Demographics
NPI:1588151997
Name:BACALLAO, RICARDO LUIS (DC)
Entity type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:LUIS
Last Name:BACALLAO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 266544
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326
Mailing Address - Country:US
Mailing Address - Phone:754-281-2443
Mailing Address - Fax:
Practice Address - Street 1:1633 N HIATUS RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-2129
Practice Address - Country:US
Practice Address - Phone:754-281-2443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12472111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor