MEDICARE: MR. JULIAN CLIFFORD MADISON III CCC

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	235Z00000X	Speech-Language Pathologist	14301141

General Provider Information

NPI Number	:	1477120814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JULIAN CLIFFORD MADISON III CCC

Provider Business Mailing Address
First Line	:	1065 E 3RD ST APT 10
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-3450
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3737 ATLANTIC AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3433
Country	:	US
Telephone Number	:	562-426-6123
Fax Number	:

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

Provider Enumeration Date	:	06/04/2021
Last Update Date	:	06/04/2021

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