Provider Demographics
NPI:1841596228
Name:ARCHIBALD, MADELYN
Entity Type:Individual
Prefix:MRS
First Name:MADELYN
Middle Name:
Last Name:ARCHIBALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12228 ROSEVILLE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2438
Mailing Address - Country:US
Mailing Address - Phone:909-899-5053
Mailing Address - Fax:
Practice Address - Street 1:12228 ROSEVILLE DR
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-2438
Practice Address - Country:US
Practice Address - Phone:909-899-5053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN5616932172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver