Provider Demographics
NPI:1164669974
Name:SHATORYA ANN MODKINS
Entity Type:Organization
Organization Name:SHATORYA ANN MODKINS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHATORYA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MODKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-208-6402
Mailing Address - Street 1:4342 LASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232-1186
Mailing Address - Country:US
Mailing Address - Phone:214-208-6402
Mailing Address - Fax:
Practice Address - Street 1:4342 LASHLEY DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-1186
Practice Address - Country:US
Practice Address - Phone:214-208-6402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization