Provider Demographics
NPI:1679105944
Name:MODRELL, JACE (PT)
Entity Type:Individual
Prefix:
First Name:JACE
Middle Name:
Last Name:MODRELL
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Gender:M
Credentials:PT
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Mailing Address - Street 1:3290 RIDGEWAY DR STE 3
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2023
Mailing Address - Country:US
Mailing Address - Phone:319-665-2630
Mailing Address - Fax:319-665-2631
Practice Address - Street 1:3290 RIDGEWAY DR STE 3
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2023
Practice Address - Country:US
Practice Address - Phone:319-665-2630
Practice Address - Fax:319-665-2631
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2022-05-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA0932672255A2300X
IA099040208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer