Provider Demographics
NPI:1801627096
Name:MOD-DOC INC.
Entity type:Organization
Organization Name:MOD-DOC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAX
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUDOIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-828-8682
Mailing Address - Street 1:1741 N 2000 W STE 4
Mailing Address - Street 2:
Mailing Address - City:FARR WEST
Mailing Address - State:UT
Mailing Address - Zip Code:84404-9811
Mailing Address - Country:US
Mailing Address - Phone:385-470-0150
Mailing Address - Fax:385-325-0186
Practice Address - Street 1:1741 N 2000 W STE 4
Practice Address - Street 2:
Practice Address - City:FARR WEST
Practice Address - State:UT
Practice Address - Zip Code:84404-9811
Practice Address - Country:US
Practice Address - Phone:385-470-0150
Practice Address - Fax:385-325-0186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty