Provider Demographics
NPI:1326122177
Name:MABOLOC, EVA PEREZ
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:PEREZ
Last Name:MABOLOC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EVA
Other - Middle Name:ASIGNAR
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPT
Mailing Address - Street 1:2105 LOUDENSLAGER DR
Mailing Address - Street 2:
Mailing Address - City:THOMPSONS STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37179-5313
Mailing Address - Country:US
Mailing Address - Phone:931-363-7548
Mailing Address - Fax:
Practice Address - Street 1:1245 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4541
Practice Address - Country:US
Practice Address - Phone:931-363-7548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist