Provider Demographics
NPI:1376956748
Name:BACULANTA, LOIDA LIM (PT)
Entity Type:Individual
Prefix:
First Name:LOIDA
Middle Name:LIM
Last Name:BACULANTA
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 1:549 N MAIN ST APT 4
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:IL
Mailing Address - Zip Code:62092-1281
Mailing Address - Country:US
Mailing Address - Phone:217-416-8032
Mailing Address - Fax:
Practice Address - Street 1:549 N MAIN ST
Practice Address - Street 2:APT 4
Practice Address - City:WHITE HALL
Practice Address - State:IL
Practice Address - Zip Code:62092-1281
Practice Address - Country:US
Practice Address - Phone:217-416-8032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.019317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist