Provider Demographics
NPI:1225694920
Name:MACIAS, ALEXANDRA (LAC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3648 W 61ST PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-3925
Mailing Address - Country:US
Mailing Address - Phone:615-984-5086
Mailing Address - Fax:
Practice Address - Street 1:7627 LAKE ST STE 201
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1878
Practice Address - Country:US
Practice Address - Phone:708-366-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001326171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist