Provider Demographics
NPI:1508293382
Name:MODOMA MEDMASSAGE, LLC
Entity Type:Organization
Organization Name:MODOMA MEDMASSAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS & FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:DAKOTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK HAWKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-213-2762
Mailing Address - Street 1:4944 PRESTON RD
Mailing Address - Street 2:STE 100A
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-8597
Mailing Address - Country:US
Mailing Address - Phone:469-213-2762
Mailing Address - Fax:
Practice Address - Street 1:4944 PRESTON RD
Practice Address - Street 2:STE 100A
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-8597
Practice Address - Country:US
Practice Address - Phone:469-213-2762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty