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General NPI Number Information
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NPI Number | 1790684264
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Entity Type | Organization
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Legal Business Name | MODERN MEDICAL WELLNESS, PLLC
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Dates
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Enumeration Date | 11/02/2026
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Last Update Date | 11/02/2026
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Provider Practice Location Address
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Address Line | 3010 WESTCHESTER AVE STE 105
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City | PURCHASE
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State | NY
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Zip | 10577-2524
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Country | US
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Telephone | 914-865-7101
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Fax |
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Provider Business Mailing Address
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Address Line | 3010 WESTCHESTER AVE STE 105
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City | PURCHASE
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State | NY
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Zip | 10577-2524
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Country | US
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Telephone | 914-865-7101
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JAN ZISLIS
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Credential | MD
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Telephone | 860-729-0960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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