Provider Demographics
NPI:1033461827
Name:MODERN CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:MODERN CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LERANDAL
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-644-9803
Mailing Address - Street 1:149 BUCK CREEK PLZ
Mailing Address - Street 2:
Mailing Address - City:ALABASTER
Mailing Address - State:AL
Mailing Address - Zip Code:35007-7005
Mailing Address - Country:US
Mailing Address - Phone:404-644-9803
Mailing Address - Fax:
Practice Address - Street 1:149 BUCK CREEK PLZ
Practice Address - Street 2:
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007-7005
Practice Address - Country:US
Practice Address - Phone:404-644-9803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty