Provider Demographics
NPI:1194346619
Name:MADERA, PRICILLA (LMT)
Entity type:Individual
Prefix:
First Name:PRICILLA
Middle Name:
Last Name:MADERA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 CENTER DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-7945
Mailing Address - Country:US
Mailing Address - Phone:541-210-5674
Mailing Address - Fax:541-210-5674
Practice Address - Street 1:1345 CENTER DR UNIT A
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7945
Practice Address - Country:US
Practice Address - Phone:541-210-5674
Practice Address - Fax:541-210-5674
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23878225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist