Healthcare Provider Details

I. General information

NPI: 1831423813
Provider Name (Legal Business Name): MICHELLE NANCY MADRID LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 W NELSON ST APT. 2
CHICAGO IL
60657-3027
US

IV. Provider business mailing address

1610 W NELSON ST APT. 2
CHICAGO IL
60657-3027
US

V. Phone/Fax

Practice location:
  • Phone: 773-307-3466
  • Fax:
Mailing address:
  • Phone: 773-307-3466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227004934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: