Healthcare Provider Details

I. General information

NPI: 1932258191
Provider Name (Legal Business Name): RANDY D. MODGLIN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 SUNSET DR STE 100
JOHNSON CITY TN
37604-2492
US

IV. Provider business mailing address

306 SUNSET DR STE 100
JOHNSON CITY TN
37604-2492
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-8304
  • Fax: 423-926-5976
Mailing address:
  • Phone: 423-926-8304
  • Fax: 423-926-5976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberDC0000001352
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License NumberDC0000001352
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1352
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC0000001352
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License NumberDC0000001352
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberDC0000001352
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC0000001352T
License Number StateTN
# 8
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC0000001352
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: