Provider Demographics
NPI:1609450089
Name:MODO BIO, LLC
Entity Type:Organization
Organization Name:MODO BIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:VISSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-681-0406
Mailing Address - Street 1:14275 N 87TH ST STE 115
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3696
Mailing Address - Country:US
Mailing Address - Phone:480-681-0406
Mailing Address - Fax:
Practice Address - Street 1:11225 WILLOW GARDENS DR
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-6020
Practice Address - Country:US
Practice Address - Phone:480-681-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty