Provider Demographics
NPI:1346296779
Name:MODRELL FAMILY AND SPORTS CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:MODRELL FAMILY AND SPORTS CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MODRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-240-4500
Mailing Address - Street 1:1550 NIAGARA RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5027
Mailing Address - Country:US
Mailing Address - Phone:970-240-4500
Mailing Address - Fax:970-240-4897
Practice Address - Street 1:1550 E NIAGARA RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5689
Practice Address - Country:US
Practice Address - Phone:970-240-4500
Practice Address - Fax:970-240-4897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804866Medicare ID - Type Unspecified