Provider Demographics
NPI:1932258191
Name:MODGLIN, RANDY D (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:D
Last Name:MODGLIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 SUNSET DR STE 100
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2492
Mailing Address - Country:US
Mailing Address - Phone:423-926-8304
Mailing Address - Fax:423-926-5976
Practice Address - Street 1:306 SUNSET DR
Practice Address - Street 2:STE 100
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2492
Practice Address - Country:US
Practice Address - Phone:423-926-8304
Practice Address - Fax:423-926-5976
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001352111NN1001X, 111NR0200X, 111NR0400X, 111NN0400X, 111NX0800X, 111N00000X
TN1352111N00000X
TNDC0000001352T111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
No111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NN0400XChiropractic ProvidersChiropractorNeurology
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3074458OtherBLUE CROSS BLUE SHIELD
350052904OtherRAILROAD MEDICARE
U65510Medicare UPIN