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General NPI Number Information
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NPI Number | 1275231276
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Entity Type | Organization
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Legal Business Name | MODERN HEALTH LLC
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Dates
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Enumeration Date | 02/20/2023
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Last Update Date | 05/14/2025
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Provider Practice Location Address
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Address Line | 2440 HIGHVIEW ST
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City | SPRING GROVE
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State | IL
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Zip | 60081-9609
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Country | US
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Telephone | 815-900-7330
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Fax | 928-268-0163
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Provider Business Mailing Address
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Address Line | 6703 BROADWAY ST
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City | RICHMOND
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State | IL
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Zip | 60071-9786
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Country | US
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Telephone | 847-417-7987
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Fax | 928-268-0163
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Authorized Official
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Title or Position | APRN
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Name | NICOLE J HENDRICKSON
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Credential | APRN
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Telephone | 847-417-7987
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LC1500X
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Taxonomy Name | Community Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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