Provider Demographics
NPI:1538281043
Name:MODERN BACK AND NECK CLINIC INC
Entity Type:Organization
Organization Name:MODERN BACK AND NECK CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-987-1466
Mailing Address - Street 1:217 E CAMP WISDOM RD STE 852
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-2703
Mailing Address - Country:US
Mailing Address - Phone:972-283-3300
Mailing Address - Fax:
Practice Address - Street 1:4041 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-4063
Practice Address - Country:US
Practice Address - Phone:972-283-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty