Healthcare Provider Details

I. General information

NPI: 1902344591
Provider Name (Legal Business Name): MODERN MOJO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 NW 4TH ST SUITE A
GRAND RAPIDS MN
55744-2714
US

IV. Provider business mailing address

28 NW 4TH ST SUITE A
GRAND RAPIDS MN
55744-2714
US

V. Phone/Fax

Practice location:
  • Phone: 218-999-7750
  • Fax:
Mailing address:
  • Phone: 218-999-7750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TONYA MARIE ZIMMERMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 218-999-7750