Provider Demographics
NPI:1275231698
Name:MODERNI SPINE PLLC
Entity Type:Organization
Organization Name:MODERNI SPINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:CAITLIN
Authorized Official - Last Name:KONRATH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:651-440-0939
Mailing Address - Street 1:6421 BLUESTEM CIR
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:MN
Mailing Address - Zip Code:55340-4112
Mailing Address - Country:US
Mailing Address - Phone:651-440-0939
Mailing Address - Fax:
Practice Address - Street 1:3454 COUNTY ROAD 101
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-1016
Practice Address - Country:US
Practice Address - Phone:651-323-0850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-16
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain