Provider Demographics
NPI:1902415078
Name:MODERN HEALTH & WELLNESS LLC
Entity Type:Organization
Organization Name:MODERN HEALTH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KETRINA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:469-659-9494
Mailing Address - Street 1:3229 WILTSHIRE HORN AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-2844
Mailing Address - Country:US
Mailing Address - Phone:702-812-9803
Mailing Address - Fax:
Practice Address - Street 1:1010 N BELT LINE RD STE 104
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-1770
Practice Address - Country:US
Practice Address - Phone:469-659-9494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty