Provider Demographics
NPI:1710307590
Name:MODERN ELIXIR
Entity Type:Organization
Organization Name:MODERN ELIXIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:NMD
Authorized Official - Phone:520-308-5280
Mailing Address - Street 1:6818 N ORACLE RD
Mailing Address - Street 2:SUITE 414
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-4249
Mailing Address - Country:US
Mailing Address - Phone:520-308-5280
Mailing Address - Fax:
Practice Address - Street 1:6818 N ORACLE RD
Practice Address - Street 2:SUITE 414
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-4249
Practice Address - Country:US
Practice Address - Phone:520-308-5280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-18699174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty