Provider Demographics
NPI:1740436203
Name:SACLOLO, LUIS L (PT)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:L
Last Name:SACLOLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-9186
Mailing Address - Country:US
Mailing Address - Phone:417-455-9435
Mailing Address - Fax:479-770-5656
Practice Address - Street 1:2525 S MARKET ST
Practice Address - Street 2:SUITE #100
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8163
Practice Address - Country:US
Practice Address - Phone:479-770-5655
Practice Address - Fax:479-770-5656
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR1655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARAR1655OtherSTATE LICENSE #: AR1655
MO105315OtherMO PT LICENSE