Healthcare Provider Details

I. General information

NPI: 1245158674
Provider Name (Legal Business Name): MADELEINE CHAO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAIN ST
SAN QUENTIN CA
94964
US

IV. Provider business mailing address

35 THOMAS DR APT 6
MILL VALLEY CA
94941-1635
US

V. Phone/Fax

Practice location:
  • Phone: 518-867-2112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: