=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609450089
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODO BIO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2021
-----------------------------------------------------
Last Update Date | 05/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11225 WILLOW GARDENS DR
-----------------------------------------------------
City | WINDERMERE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34786-6020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-681-0406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14275 N 87TH ST STE 115
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-3696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-681-0406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | GARY VISSER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 480-681-0406
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------