Provider Demographics
NPI:1477920882
Name:MODERN CREATIONS CONSTRUCTION
Entity Type:Organization
Organization Name:MODERN CREATIONS CONSTRUCTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CONTRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:F
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:CONTRACTOR
Authorized Official - Phone:505-720-8040
Mailing Address - Street 1:9716 TORRISO CT SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-5280
Mailing Address - Country:US
Mailing Address - Phone:505-720-8040
Mailing Address - Fax:
Practice Address - Street 1:9716 TORRISO CT SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-5280
Practice Address - Country:US
Practice Address - Phone:505-720-8040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94565332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies