Provider Demographics
NPI:1558015255
Name:MODERN HEALTH CONNECTIONS LLC
Entity Type:Organization
Organization Name:MODERN HEALTH CONNECTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:SST
Authorized Official - Phone:313-377-2018
Mailing Address - Street 1:11383 MARK TWAIN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-3051
Mailing Address - Country:US
Mailing Address - Phone:313-506-5739
Mailing Address - Fax:
Practice Address - Street 1:11383 MARK TWAIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-3051
Practice Address - Country:US
Practice Address - Phone:313-506-5739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-10
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health