Basic Information
| Provider Information | |||||||||
| NPI: | 1003292459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADRIGAL | ||||||||
| FirstName: | JOSE | ||||||||
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| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 N LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | GRIFFITH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463191125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199476085 | ||||||||
| FaxNumber: | 2199476356 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 N LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | GRIFFITH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463191125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199476085 | ||||||||
| FaxNumber: | 2199476356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2015 | ||||||||
| LastUpdateDate: | 08/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 36000657A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.