Provider Demographics
NPI:1720552037
Name:MADRIGAL CAMPOS, IRMA (RD)
Entity Type:Individual
Prefix:
First Name:IRMA
Middle Name:
Last Name:MADRIGAL CAMPOS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5761 SANTA MONICA BLVD APT 6
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-3216
Mailing Address - Country:US
Mailing Address - Phone:323-443-4063
Mailing Address - Fax:
Practice Address - Street 1:2411 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2218
Practice Address - Country:US
Practice Address - Phone:323-987-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered