Provider Demographics
NPI:1336957992
Name:MADRIGAL, ALISHA (PARAMEDICAL TATTOO)
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:
Last Name:MADRIGAL
Suffix:
Gender:F
Credentials:PARAMEDICAL TATTOO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 S CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3940
Mailing Address - Country:US
Mailing Address - Phone:209-642-6054
Mailing Address - Fax:
Practice Address - Street 1:1110 W KETTLEMAN LN STE 30
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-6047
Practice Address - Country:US
Practice Address - Phone:209-217-1067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty