Provider Demographics
NPI:1679265417
Name:MODERN SPINE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:MODERN SPINE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:787-486-7919
Mailing Address - Street 1:URB LAS ALONDRAS A10 CALLE 1
Mailing Address - Street 2:
Mailing Address - City:VILLALBA
Mailing Address - State:PR
Mailing Address - Zip Code:00766-2301
Mailing Address - Country:US
Mailing Address - Phone:787-486-7919
Mailing Address - Fax:
Practice Address - Street 1:1228 AVE MUNOZ RIVERA STE 1
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-0639
Practice Address - Country:US
Practice Address - Phone:939-500-0649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty