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General NPI Number Information
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NPI Number | 1679265417
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Entity Type | Organization
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Legal Business Name | MODERN SPINE CHIROPRACTIC LLC
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Dates
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Enumeration Date | 05/22/2023
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Last Update Date | 05/22/2023
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Provider Practice Location Address
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Address Line | 1228 AVE MUNOZ RIVERA STE 1
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City | PONCE
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State | PR
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Zip | 00717-0639
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Country | US
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Telephone | 939-500-0649
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Fax |
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Provider Business Mailing Address
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Address Line | URB LAS ALONDRAS A10 CALLE 1
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City | VILLALBA
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State | PR
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Zip | 00766-2301
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Country | US
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Telephone | 787-486-7919
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | RAFAEL M MIRANDA
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Credential | DC
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Telephone | 787-486-7919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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