Provider Demographics
NPI:1275231276
Name:MODERN HEALTH LLC
Entity Type:Organization
Organization Name:MODERN HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:847-417-7987
Mailing Address - Street 1:6703 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IL
Mailing Address - Zip Code:60071-9786
Mailing Address - Country:US
Mailing Address - Phone:847-417-7987
Mailing Address - Fax:928-268-0163
Practice Address - Street 1:2440 HIGHVIEW ST
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081-9609
Practice Address - Country:US
Practice Address - Phone:815-900-7330
Practice Address - Fax:928-268-0163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-20
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty