MEDICARE: LILIAN MARISOL ROSALES MADRID

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174N00000X	Lactation Consultant (Non-RN)

General Provider Information

NPI Number	:	1811621543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILIAN MARISOL ROSALES MADRID

Provider Business Mailing Address
First Line	:	26 WESLEY DREW LN NW
Second Line	:
City	:	CARTERSVILLE
State	:	GA
Zip	:	30121-4636
Country	:	US
Telephone Number	:	706-266-1014
Fax Number	:

Provider Business Practice Location Address
First Line	:	2141 KINGSTON CT SE STE 103
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-8928
Country	:	US
Telephone Number	:	770-644-0555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2022
Last Update Date	:	07/09/2022

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