Healthcare Provider Details

I. General information

NPI: 1972827574
Provider Name (Legal Business Name): MODERN ELIXIR, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 10/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6818 N ORACLE RD SUITE 414
TUCSON AZ
85704-4249
US

IV. Provider business mailing address

6818 N ORACLE RD SUITE 414
TUCSON AZ
85704-4249
US

V. Phone/Fax

Practice location:
  • Phone: 520-308-5280
  • Fax: 520-308-5281
Mailing address:
  • Phone: 520-308-5280
  • Fax: 520-308-5281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21070
License Number StateAZ

VIII. Authorized Official

Name: DR. JUSTIN K. TAYLOR
Title or Position: PHYSICIAN
Credential: N.M.D.
Phone: 520-981-5042