Provider Demographics
NPI:1669018065
Name:MODEN, ELIZABETH MARIE (DC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:MODEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4561 LEWIS DR
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5428
Mailing Address - Country:US
Mailing Address - Phone:716-863-3133
Mailing Address - Fax:
Practice Address - Street 1:3685 HARLEM RD STE 3
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-2046
Practice Address - Country:US
Practice Address - Phone:716-863-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013302111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor