Provider Demographics
NPI:1568998482
Name:MACIOCH, ALISIA KAYE (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ALISIA
Middle Name:KAYE
Last Name:MACIOCH
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-2624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 COUNTY ROAD B2 W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4338
Practice Address - Country:US
Practice Address - Phone:651-301-2279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN31382081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program