Provider Demographics
NPI:1073025185
Name:MODERN CHIROPRACTIC & WELLNESS,LLC
Entity Type:Organization
Organization Name:MODERN CHIROPRACTIC & WELLNESS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETRO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:216-712-6820
Mailing Address - Street 1:1454 GENTRY MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-6940
Mailing Address - Country:US
Mailing Address - Phone:864-644-2700
Mailing Address - Fax:864-644-2710
Practice Address - Street 1:21800 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-3331
Practice Address - Country:US
Practice Address - Phone:216-712-6820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSU139070111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4572OtherCHIROPRACTIC MEDICAL LICENSES