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General NPI Number Information
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NPI Number | 1255088720
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Entity Type | Organization
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Legal Business Name | MODERN MEDICINE PLLC
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Dates
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Enumeration Date | 03/04/2022
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Last Update Date | 03/14/2022
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Provider Practice Location Address
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Address Line | 919 REINICKE ST STE A
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City | HOUSTON
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State | TX
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Zip | 77007-5191
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Country | US
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Telephone | 346-351-7958
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Fax | 803-932-9618
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Provider Business Mailing Address
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Address Line | 919 REINICKE ST STE A
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City | HOUSTON
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State | TX
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Zip | 77007-5191
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Country | US
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Telephone | 346-351-7958
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Fax | 803-932-9618
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Authorized Official
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Title or Position | MD
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Name | KEVIN TAVANGARIAN
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Credential | MD
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Telephone | 832-607-5704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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