=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528677499
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MILAN MODI DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2020
-----------------------------------------------------
Last Update Date | 07/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3225 SHALLOWFORD RD STE 700
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30062-7026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-353-9339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3929 CYRUS CREST CIR NW
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30152-2521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-207-9565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIR010314
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------